Fitzgerald Review FNP Flashcards

Question

LAIV Vaccine

Answer 1

Give age 2-49 years Do not give in pregnant women, immunosupression, history of egg allergy, airway disease, people who have received flu antiviral in the last 48 hours

Answer 2

5-10% The majority within the first 5 years

Answer 3

Birth 1-2 months 6-18 months

Answer 4

2, 4, 6 months Max age for final dose 8 months

Answer 5

Dtap 2, 4, 6 months 15-18 months 4-6 years (Tdap at 11-12 years)

Answer 6

ActHIB: 3 doses 2, 4, 6 months PedvaxHIB: 2 doses 2, 4, months Booster at 12-15 months

Answer 7

Prevnar PCV 13 4 doses 2, 4, 6 and 12-15 months

Answer 8

2 months 4 months 6-18 months 4-6 years

Answer 9

2 doses 12-15 months 4-6 years doses minimum 4 weeks apart May give 2nd dose of MMR before age 4 if 3 months since first dose

Answer 10

1st dose at 12-23 months 2nd dose 6-18 months later - 6 months minimum time between doses

Answer 11

Recommended starting age 60 years per ACIP FDA licensed for adults 50 years and older

Answer 12

Previously unimmunized 65 years and older - PCV13 then PPSV23 6-12 months later If have received PPSV23 at age 65 or older, PCV13 1 year after PPSV23 dose If PPSV23 received before age 65, give PCV13 1 year after most recent dose of PPSV23, then PPSV23 6-12 months later (and at least 5 years has passed since most recent dose of PPSV23)

Answer 13

PPD x years smoked

Answer 14

Males \> 65 years

Answer 15

Pt not interested in change Unaware of problem Minimizes impact

Answer 16

Considering change Feels stuck HCP to examine barriers

Answer 17

Some change behaviors Does not have tools to proceed HCP to assist in finding tools, removing barriers

Answer 18

Ready to go through w/ change Inconsistent in carrying through HCP to work w/ patient encourage healthy behavior, praise positive, acknowledge regression is common but not unsurmountable

Answer 19

Has adopted and embraced healthy habit Relapse can occur HCP to continue positive reinforcement Backsliding is common but not insurmountable

Answer 20

Heart Disease Cancer a close second d/t rising gero population

Answer 21

**Cases** Male: Prostate, Lung, Colon Female: Breast, Lung, Colon **Deaths** Male: Lung, prostate, colon Female: Lung, breast, colon

Answer 22

Mammography annually starting age 40 High risk (\> 20% lifetime risk): MRI + mammography annually Yearly MRI not recommended if lifetime risk \< 15% CBE every 3 years for women 20-40 years CBE every year 40 years and older

Answer 23

FOBT/FIT annually starting at 50 years Colonoscopy if FOBT/FIT positive Preferred FOBT/FIT method: two samples from 3 consecutive specimens collected by pt at home **OR** Flexible sigmoidoscopy every 5 years starting at 50 Colonoscopy if positive OR Double-contrast barium enema every 5 years starting at 50 Colonoscopy if positive OR Colonoscopy every 10 years starting at age 50

Answer 24

History of colon cancer, adenomatous polyps, Crohn disease, or Ulcerative Colitis, strong family history (colon cancer of first degree relative before age 60, or 2 or more first-degree relatives at any age). Ulcerative Colitis: start colonoscopy 12 years after onset, then every thereafter Crohns: start colonoscopy 8 years after onset, then every year thereafter

Answer 25

Start discussion at 50 years for men at average risk w/ 10 year life expectancy Prostate cancer grows slowly, if \< 10 year life expectancy, not likely to benefit

Answer 26

Women at menopause Report unexpected bleeding Abnormal vaginal bleeding is presenting sign in 90% of women with endometrial carcinoma For women with hereditary non-polyposis colon cancer (HNPCC), annual screening with EMB beginning at 35 years

Answer 27

Age 55-74 years with 30 pack year smoking history, current smokers, or 15 years or less since quitting: Annual low dose CT until age 74 years

Answer 28

PAP smear starting age 21 every 3 years Cytology + HPV every 5 years starting 30 years of age

Answer 29

90% renal, 10% hepatic Diminished in advancing renal failure, usually beginning when GFR \< 49 mL/min

Answer 30

Reticulocyte count responds in 1 week Hgb in 1 month 1gm/dL per month Ferritin in 4-6 months

Answer 31

Chronic PPI use Long-term Metforming use

Answer 32

7+ years of B12 stored in liver will take 7+ years to be depleted

Answer 33

GI immaturity allowing reflux

Answer 34

1-3 hours after injection

Answer 35

Use of single-use injection drug paraphernalia

Answer 36

Gastroparesis

Answer 37

B-lymphocyte stimulater-specific inhibitor first biologic agent approved for adults with SLE

Answer 38

AKA: Migrainous neuralgia, Suicide headaches Only primary headache M \> F Most common in middle-aged men, likely underdiagnosed in women

Answer 39

Contraindicated in pregnant women d/t potential vasoconstrictor effects

Answer 40

Most often found in women Condition usually appears between age 15 and 45

Answer 41

Primary adrenal insufficiency Key risk factor: autoimmune conditions E.g. chronic thyroiditis, dermatitis herpetiformis, Graves, hypoparathyroidism, myasthania gravis, Type I DM

Answer 42

Iron deficiency anemia

Answer 43

Chronic low volume blood loss

Answer 44

1. Chronic disease 2. IDA 3. Pernicious anemia (distant)

Answer 45

Hemolytic anemia

Answer 46

Recycled iron content from aged RBCs 85% typically comes from old RBCs

Answer 47

MCV \> 125 | (most macrocytic)

Answer 48

RDW starts to normalize as soon as tx started

Answer 49

On an empty stomach GI upset common Try w/o food, if GI upset, take w/ breakfast and dinner in divided doses BID best frequency Duodenum is where iron is absorbed, after a big dose of iron, intestines cannot absorb more for another 6 hours Enteric coated iron = very little is absorbed as a lot of is released beyond the duodenum

Answer 50

Beta thalassemia major Life threatening w/o intervention dx shortly after birth

Answer 51

Inflammation of paranasal sinuses/nasal mucosa lasting up to 4 weeks Caused by allergens, environmental irritants, and/or infections Infectious causes: virus (majority), bacteria, fungi

Answer 52

Secondary bacterial infection usually following a viral URI Less than 2% of viral URIs are complicated by ABRS Vast majority will clear w/o abx

Answer 53

Age \< 2 or \> 65 Prior abx in the past month Prior hospitalization within past 5 days Comorbidities Immunocompromised

Answer 54

Disproven as diagnostic for sinusitis

Answer 55

**First Line:** Amoxicillin-Clav 500/125 PO TID or 875/125 BID **Second Line:** Doxy 100 mg BID - (note: DRSP tx failure risk) **In beta-lactam allergy:** Doxy 100 mg BID Levo 500 mg daily Moxi 400 mg daily **If DRSP risk: Respiratory fluroquinolone**

Answer 56

Erythromycin Clarithromycin Increases toxicity e.g. Clarithro + Statin = 15x statin dose = rhabdo

Answer 57

Hive-form/urticaria Angioedema

Answer 58

Pushes substrate OUT the exit pathway = decreased substrate levels E.g. St. John's Wort

Answer 59

slowly progressive, symmetric, predominantly high frequency hearing loss

Answer 60

Reversible Something in between sound and auditory apparatus OME: can persist for up to 3 months; treatment is TIME

Answer 61

Inability to discriminate human voice in a noisy environment During exam, HCP to: face-to-face Eye-level quiet environment

Answer 62

allergen-induced upper airway inflammation and hypersensitivity d/t genetic-environmental interactions **s/sx** nasal discharge, sneezing, nasal congestion, anosmia, and nasal/pharyngeal/ocular itch

Answer 63

First line Intranasal corticosteroids e.g. Flonase 1 spray BID or 2 sprays daily Onset of action within 12-24 hours Optimal efficacy can take 1-2 weeks Very low-dose Low systemic absorption

Answer 64

Diphenhydramine, Chlorpheniramine, Brompheniramine, Hydroxyzine Blocks histamine-1 receptor sites Significant SE: sedation, impairs performance, ANTICHOLINERGIC effects Problematic in older adult

Answer 65

Olopatadine (Patanol, Pataday) For ocular allergy symptoms Drop might sting for a few seconds Will not sting once inflammation goes down

Answer 66

Alpha-adrenargic AGONIST Relieves congestion via vasoconstriction Caution w/ elderly, young children, HTN, bladder neck obstruction, glaucoma, and hyperthyroidism

Answer 67

Afrin Effective in ABRS Rebound congestion/rhinitis may occur LIMIT USE TO 5-7 days

Answer 68

Dry as a bone (dry mouth) Red as a beet (flushing) Mad as a hatter (confusion) Hot as a hare (hyperthermia) Can't see (vision changes) Can't pee (urinary retention) Can't spit (dry mouth) Can't shit (constipation)

Answer 69

Painless Firm Immobile

Answer 70

90% squamous cell

Answer 71

Oculomotor Eyelid and eyeball movement

Answer 72

Trochlear Turns eye downward and laterally

Answer 73

Trigeminal Chewing Face, mouth sensation and pain

Answer 74

Abducens Turns eye laterally

Answer 75

Facial Facial expressions, secretion of tears, saliva, taste

Answer 76

Acoustic Hearing, equilibrium, sensation

Answer 77

Glossopharyngeal Taste, senses carotid BP

Answer 78

Vagus Senses aortic BP Slows HR Stimulates digestive organs, taste

Answer 79

Spinal accessory Controls trapezius and sternocleinomastoid Controls swallowing movements

Answer 80

Hypoglossal Controls tongue movements

Answer 81

Red Eye Painful Acute vision change

Answer 82

Most common cause of new onset vision loss in elderly F \> M Female retina likes estrogen, post-menopause, eye ages rapidly Central vision loss Test: Amsler grid test

Answer 83

Thief of the night d/t progressive and aymptomatic presentation Enlarged optic disc cupping Loss of visual fields \>90% of glaucoma cases Gradual blockaage of aqueous flow despite apparently open system

Answer 84

African ancestry DM Family Hx History of eye trauma/uveitis Advacing age

Answer 85

Narrow angle glaucoma \< 10% of glaucoma Most serious form s/sx Injected conjunctiva Very painful N&V If drainage is only partially blocked: only warning signs may be blurry vision and colored halos around lights

Answer 86

Anticholinergics Steroids Sympathomimetic pupil dilating drops TCAs MAOIs Antihistamines Antipsychotic meds Sulfonamides Antispasmolytic agents

Answer 87

First line: topical prostaglandins Latonoprost (Xalatan) - 1 drop in affected eye daily in the evening Bimatoprost (Lumigan) - 1 drop affected eye daily in the evening - Beta-blockers: Timolol 1 drop BID Alpha-adrenergic agonists: Alphagan 1 drop TID

Answer 88

Acute primary attack: Prompt IOP lowering eye drops (Timolol, Iodipine, pilocarpine) Oral or IV acetazolamide or oral glycerold isosorbide: Give two 250 mg Acetazolamide tablets in the office, recheck eye-pressure 30-60 minutes later Systemic medication other than acetazolamide should be given under guidance of an ophthalmologist Once attack is broken, treatment of choice: laser peripheral iridotomy If laser peripheral iridotomy fails to remain patent or if cornea too cloudy, surgical peripheral iridectomy may be necessary

Answer 89

Ofloxacin otic 10 drops BID x 14 days (Ofloxacin also used for otitis externa 10 drops daily x 7 days)

Answer 90

Clotrimazole 1% BID x 14 days then re-assess If fungal elements persist, clean meticulously then treat for another 10-14 days Refer to ENT if persisting

Answer 91

Diminished sense of smell, age-related, accelerated by tobacco use

Answer 92

Lens clouding Progressive vision dimming Risk Fx: tobacco, poor nutrition, sun exposure, systemic steroids Potentially correctable w/ surgery, lens implant

Answer 93

Hardening of lens Near all 45 years and older need reading glasses

Answer 94

S. aureus S. pneumo H. influenzae Outbreaks d/t atypical S. pneumo

Answer 95

Primary tx: Fluroquinolone ophthalmic solution (preferred in contact lens wearers d/t pseudomonas coverage) Alternative: Polymyxin B w/ trimethoprim or azithromycin 1% opththalmic solution **DOSE:** **0.5 inch of ointment inside lower lid** **OR** **1-2 drops** **QID x 5-7 days** Ointment preferred in kids, those w/ poor compliance as ointment stays on lids Drops preferred in adults who need to read/drive as ointment clouds vision for 20 minutes after admin.

Answer 96

Do NOT use neomycin containing ointment if ruptured TM **USE:** **Ofloxacin otic drops** **5 drops BID x 3-5 days** **AND** **Amox 500 mg TID x 5-7 days** **If PCN allergy** - Cefdinir 300 mg BID - Cefpodoxime 200 mg BID - Cefuroxime 500 mg BID - Ceftriaxone 2 g IM **If beta-lactam allergy:** - Erythromycin combine with sulfisoxazole - Azithromycin - Clarithromycin **If tx failure:** Cefuroxime 250 mg BID x 10 days Augmentin 875/125 BID x 5-7 days (10 days if severe) -- Avoid acidic/antiseptic agents TM should heal within days Prevent water entry into ear canal while healing Follow up in 4 weeks to reassess and for audiometry ENT referral if persistent perforation or hearing loss \> 4 weeks of injury

Answer 97

Group A, C, G strep Viral HHV-6 M. Pneumo

Answer 98

First line: Penicillin V 500 mg 3-4x/day x 10 days **Alternative:** Erythromycin x 10 days Second generation cephalosporin x 4-6 days Azithromycin x 5 days Clarithromycin x 10 days Note: Up to 35% of S. pyogenes are resistant to macrolides

Answer 99

**Cefazolin**, cephalexine, cephapirin, cefadroxil, cephadrine, cephalotin Active against most gram+ cocci except for enterococci, oxacillin-resistant staph, and PCN-resistant pneumococci Active again most E-coli strains, proteus mirabillis, and klebsiella

Answer 100

**cefuroxime,** **cefoxitin**, cefotetan, **cefprozil**, cefactor, cefonicid, cefamandole, cefmetazole - somewhat less active against gram positive cocci than first gen more active against certain gram negative bacilli Cefuroxime - active against Haemophilus influenzae Cefoxitin and cefotetan - active against most E. coli, P. mirabillis, and Klebsiella, active against Bacteroides

Answer 101

**Ceftriaxone, Cefdinir, Cefixime,** Cefotaxime, Ceftazidime, Cefpodoxime, Cefditoren, Cefoperazone, Ceftibuten Marked by stability to the common beta-lactamases of gram-negative bacilli Useful alternatives to aminoglycosides in treating gram-negative infections resistant to other beta-lactams, esp. in patients with renal dysfunction

Answer 102

Cefepime Only one

Answer 103

Ceftaroline

Answer 104

Oral cipro 750 mg BID for early disease suitable for outpatient Inpatient IV tx in severe disease - Tx typically started IV then orally Riskf or osteomyelitis of skull/TMJ MRI or CT indicated to r/o osteomyelitis often indicated ENT consult w/ surgical debridement should be considered Obtain cultures of ear drainage or results of surgical debridement

Answer 105

Fungi rare Pseudomonas, Proteus, Enterobacteriaceae Acute infection often S. aureus Tx: MILD: Acetic acid w/ propylene glycol and hydrocortisone (VoSol) drops MODERATE-SEVERE: Otic drops with ciprofloxacin with hydrocortisone DO NOT USE NEOMYCIN IF TM RUPTURE SUSPECTED

Answer 106

Systemic abx seldom needed Ear canal cleansing: decrease risk of infection by use of eardrops 1:2 mixture of white vinegar and rubbing alcohol after swimming

Answer 107

Will help with itchy/watery eyes, sneezing and rhinorrhea Antihistamines will not help with nasal congestion

Answer 108

Is the patient otherwise well? = localized skin infection (acne, rosacea, kp, seborrheic derm) Is patient miserable but not systemically ill? = uncomfortable with itch, burning, pain (severe psoriasis, Norwegian scabies, herpes zoster) Is patient systemically ill? = Systemic disease (varicella, transepidermal necrosis, SJS/erythema multiforme, Lyme disease) Are there primary/secondary lesions? = Where is the _oldest_ lesion and _when_ did it occur? Where is the _newest_ lesion and _when_ did it occur?

Answer 109

PRIMARY Result from disease process. No alteration from outside manipulation/tx/natural course of disease. Eg. vesicle SECONDARY Lesions altered by outside manipulation/tx/course of disease. Eg. crust

Answer 110

Psoriasis Pinpoint bleeding when scale is scraped off.

Answer 111

Autoimmune against melanocytes Common w/ other autoimmune diseases (thyroid)

Answer 112

NEVER BENIGN "blueberry muffin" appearance e.g. Meninigitis rash

Answer 113

flat, nonpalpable discoloration e.g. Freckle

Answer 114

Solid elevation e.g. raised nevus

Answer 115

Papule with indented center e.g. Molluscum contagiosum

Answer 116

Vesicle-like lesion with purulent content e.g. Impetigo

Answer 117

\> 1 cm flat, nonpalpable discoloration e.g. Vitiligo

Answer 118

\> 1 cm Raised lesion, same or different color of surrounding skin, can result from coalescence of papules e.g. Psoriasis

Answer 119

\> 1 cm Fluid filled (bigger than vesicle) e.g. Necrotizing fasciitis

Answer 120

Any size Raised, enxapsulated, fluid-filled lesion Always benign e.g. Intradermal cyst

Answer 121

Any sized Circumscribed area of skin edema e.g. Hives

Answer 122

Purpura \> 1 cm Petechiae Flat red-purple discoloration caused by RBCs lodged in the skin Do **NOT** blanch (vascular lesion = blanches)

Answer 123

Linear, raised, often covered with crust. e.g. scratch marks over pruritic areas

Answer 124

Raised lesions produced by dried serum and blood remnants e.g. scab

Answer 125

Skin thickening usually found over pruritic or friction areas e.g. Callus

Answer 126

Raised superficial lesiosn that flake with ease e.g. Dandruff

Answer 127

Loss of epidermis e.g. area under vesicle

Answer 128

Loss of epidermis AND dermis e.g arterial ulcer Chancre

Answer 129

Narrow linear crack into epidermis, exposing dermis e.g. athletes foot

Answer 130

In a RING e.g. Erythema migrans ("bull's eye") in Lyme disease

Answer 131

Generalized over body w/o specific pattern or distribution e.g. maculopapular rash in rubella

Answer 132

Multiple lesions bleding together

Answer 133

Occurring ina group with pattern e.g. Acne-form drug induced rash seen with lithium, phenytoin, and iodine use = anticipated adverse effect

Answer 134

In streaks e.g. Contact dermatitis poison ivy

Answer 135

Appearing in a net-like cluster e.g. Erythema infectiosum (Fifth Disease/slapped cheek)

Answer 136

Limited to boundaries of a single or multiple dermatomes e.g. Shingles NOTE: If suspected, start on high-dose acyclovir and come back in 24 hours to confirm dx Pain occurs 1-2 days before lesions erupt Suspect in acute shoulder/back pain, skin is "sore" Skin could also itch severely

Answer 137

Infants vulnerable - vaccine is given at year 2-3 mm vesicles that start on trunk, appear on limbs 2-3 days later Nonclustered lesions at a variety of stages Mild to moderately ill Miserably itchy, risk for bacterial suprainfection of lesions **Tx:** Acyclovir within 24-48 hours of eruption **Prevention:** Varicella vaccine = 80% lifetime immunity first dose, 99% lifetime immunity second dose

Answer 138

Typically 50 years or older Possible in anyone with history of varicella Vesicles in a unilateral dermatomal pattern, slowly resolving with crusting Usually not systemically ill but quite miserable with pain and itch. Complications include postherpetic neuralgia, ophthalmologic involvement, and superimposed bacterial infection. **Tx:** High-dose acyclovir within 72 hours of eruption helps minimize duration and severity of illness **Prevention:** Zoster vaccine

Answer 139

Predominantly on sun-exposed skin Size ranges On skin surface - red, brown, scaly, often tender but usually minimally symptomatic Occassional flesh-colored - more easily felt than seen **Most common precancerous lesion though possibly represent early-stage SCC** **1 in 100 will progress to SCC** Tx: Topical 5-FU, 5% imiquimod cream, topical diclofenac gel or photodynamic therapy with topical delta-aminolevulinic acid Cryosurgery w/ liquid nitrogen, laser resurfacing, chemical peel

Answer 140

More common than SCC Sun-exposed area Arises de novo (of new) Papule, nodule w/ or w/o central erosion Pearly or waxy appearance, usually relatively distinct borders w/ or w/o telengiectasia Metastatic risk low

Answer 141

Less common than BCC Sun-exposed areas Can arise from AK or de novo Red, conical hard lesions w/ or w/o ulceration Less distinct borders Metastatic risk greater (3-7%) Greatest metastatic risk = lesion on lip, oral cavity, genitalia

Answer 142

A - Asymmetric B - Irregular borders C - Color not uniform D - Diameter usually 6mm or \> E - Evolving (new) lesion or change in a longstanding lesion, particularly in a nevus or other pigmented lesion E - Elevated (not consistently present) \* Majority of melanoma are de novo

Answer 143

medium-potency topical corticosteroid

Answer 144

Topical metronidazole

Answer 145

Acute, self-limited, erythematous skin disease Most likely viral Herald patch X-mas tree pattern Prodrome might occur but typically asymptomatic aside from itching Most cases do not require tx, may use medium-potency topical corticosteroid for itching Acyclovir may be useful in severe disease in shortening length of disease

Answer 146

cutaneous manifestation of hyperinsulinemia puberty = worsenign insulin resistance can regress w/ control of disease e.g. after gastric bypass

Answer 147

Infection of upper dermis, superficial lymphatics Streptococcus pyogenes (aka GABHS)

Answer 148

Infection of dermis and subcutaneous fat Streptococcus pyogenes, less commonly MSSA beta-lactamase producing, MRSA (resistance via altered protein-binding sites)

Answer 149

Skin infection involving hair follicle and surrounding tissue Carbuncles = cluster of furuncles connected subcutaneously, causing deeper suppuration and scarring Staph aureus (MSSA, MRSA)

Answer 150

**Necrotizing infection/Cellulitis/Erysipelas** Moderate = inpatient for IV PCN or Ceftriaxone, Cefazolin, or Clindamycin Mild = Oral Rx of PCN VK or Cephalosporin or Dicloxacillin or Clindamycin Dicloxacillin = PCN stable in beta-lactamase Clindamycin = most common abx assoc. w/ c-diff; take with probiotic

Answer 151

**Furuncle/Carbuncle/Abscess** Mild = I & D Moderate = I & D and C & S Empiric therapy with Bactrim, Doxy Defined Rx MRSA = Bactrim MSSA = Dicloxacillin or Cephalexin \*Keflex = First gen $4

Answer 152

"Red, white, and blue" Central blistering with surrounding gray to purple discoloration at bite site Surrounded by ring of blanched skin surrounded by large area of redness

Answer 153

Narrow spectrum Beta-lactamase resistant PCN Use of not risk factors for MRSA

Answer 154

Tick-borne Most cases occur in spring or early summer Early in disease: fever, malaise, arthralgias, headache, nausea w/ or w/o vomiting; children might present w/ abd pain Rash between day 3 and 5 of illness Early disease = empiric tx based on clinical judgment and epidemiological likelihood Later disease = dx via skin bx or serological testing

Answer 155

Start within 5 days of symptom onset Doxycycline 200 mg/day in two divided doses Tx should continue until 3 days of patient being afebrile Doxy: risk of _dental staining_ in children Doxy typically tolerated well except for _N&V_, give antiemetics/antimotility agents as needed Doxy assoc. w/ _photosensitivity_ = counsel about skin protection Pregnancy: use chloramphenicol if available

Answer 156

Erythema migrans (central erythema, ring remains flat, blanches, does not desquamate) **Tx:** Doxy 100 mg BID x 10-21 days Amox 500 mg every 6-8 hours for 21 to 30 days Cefuroxime 500 mg BID x 20 days Use Amox/Ceftin for children **Prophylaxis:** Within 72 hours of tick removal: Doxy 200 mg x 1 dose

Answer 157

Bactrim DS = 2 tablets x 5-10 days Rifampin can be added - use w/ caution CYP450 inducer If can't have sulfa (bactrim), use: Doxy Minocycline To cover staph and strep use Bactrim with a beta-lactam (cephalosporin)

Answer 158

Avoid sun exposure Lightweight long pants, long-sleeved shirts, brimmed hats May apply sunscreen 15 spf or \> minimal amt If sunburned - apply cold compresses to affected area

Answer 159

Hat w/ 3 inch brim or bill facing forward Sunglasses that block 99 to 100% of UV, cotton clothing w/ tight weave Stay in shade limit sun exposure during peak intensity hours 10 and 4 Use SPF 15 or \> on both sunny and cloudy days Protect against UVB and UVA rays Apply enough sunscreen 1 oz (30 mL) per sitting for older child and adult Reapply every 2 hours or after swimming/sweating Extra caution near water, sand, snow (reflects UV rays)

Answer 160

Skin = decreased cell turnover, decreased subum = thick and dry Hung-up patellar reflex, slow arc out, slower arc back Overall hyporeflexia Mentation = slow thoughts Weight change (5-10 lbs gain largely fluid) Stool = constipation Mentrual = menorrhagia Heat/cold tolerance = easily chilled

Answer 161

Hashimoto thyroiditis (most common) = autoimmune Post-radioactive iodine (RAI) = s/p Graves disease tx or thyroid ca tx Select medication use = lithium, amiodarone, interferon

Answer 162

Excessive cellular energy release Skin = increased cell turnover = smooth, silky Hyperreflexia Mentation = mind racing Weight change = loss 10 lbs on average Stool pattern = frequent, low volum, loose Mentrual = oligomenorrhea Heat intolerance

Answer 163

Graves disease (most common) = autoimmune, multisystem presentation (exophthalmos, tachycardia, proximal muscle weakness, goiter) Toxic adenoma (benign metabolically active nodule) Thyroiditis (viral or autoimmune, post-partum, drug-induced, often transient, usually accompanied by thyroid tenderness) Select medication use (Amiodorane, interferon)

Answer 164

0.4 to 4.0 mIU/mL

Answer 165

Reflects anterior pituitary lobe's ability to detect amount of circulating free thyroxine (T4) TSH receptors found in thyroid follicular cells Receptor stimulation = increases T3 and T4 production/secretion Single most reliable test to dx all common forms of hypo/hyperthyroidism in the ambulatory setting

Answer 166

NL = 10-27 pmo/L Unbound, metabolically active portion of thyroxine About 0.025% of all T4

Answer 167

Rarely indicated Total of protein-bound and free thyroxine Often altered in the absence of thyroid disease

Answer 168

Rarely indicated unbound, metabolically active portion of triidothyronine (T3) T3 4x more active than T4 About 20% of circulating T3 is from thyroid, 80% is from conversion of T4 to T3

Answer 169

Rarely indicated Reflects total protein-bound and free triidothyronine (T3) Often altered in the absence of thyroid disease

Answer 170

Test to help detect autoimmune thyroid disease Measures an antibody against peroxidase, an enzyme held within the thyroid

Answer 171

Need increases when metabolic need needs increases 50% or \> increased need in pregnancy Increase dose by 33% as soon as pregnancy confirmed Use ideal body weight in obesity, actual body weight in healthy weight/underweight Check TSH after 6-8 weeks Levothyroxine = long half-life, takes 3-5 half-lives to reach steady state + few more weeks for body to acclimate T3 = short half life (Armour Thyroid T3/T4 preparation) Levothyroxine: Take with water on an empty stomach same time every day Should not be taken within 2 hours of cation such as calcium, iron, aluminum, magnesium

Answer 172

Low TSH, high free T4 Tx: Beta-adrenergic antagonist with B1, B2 blockade (propranolol, nadolol) if not contraindicated to counteract tachycardia, tremor Antithyroid medication: Propylthiouracil (PTU) Methimazole (Tapazole) \*Consult with endo: black box warning for acute liver failure -- Radioactive iodine (RAI) with end-result thyroid ablation and hypothyroidism

Answer 173

Elevated TSH w/ normal free T4 AACE recommends tx of patients with TSH \> 5 if patient has goiter or if thyroid antibodies are present Presence of sx = tx

Answer 174

0.5 to 2.0 Symptom resolution Measure TSH at 6 months then annually or when symptomatic -- If TSH \> 4 Increase dose by 12.5 to 25 mcg/day If TSH Decrease dose by 12.5 to 25 mcg/day

Answer 175

atrial fibrillation

Answer 176

5% | (similar to breast bx rates)

Answer 177

history of head or neck irradiation Size \> 4 cm Firmness, nontender Immobile Persistent, nontender cervical

Answer 178

If palpable nodule (clinically evident) Order TSH and U/S TSH suppressed = metabolically active nodule = thyroid scan HOT nodule = always benign = tx with RAI COLD nodule = fine-needle aspiration bx TSH not suppressed = fine-needle aspiration bx

Answer 179

SNOOP S - systemic sx (fever, weight loss), secondary risk fx (HIV, ca, pregnancy, anticoagulation, HTN) N - neurologic signs (confusion, impaired alertness, nuchal rigidity, HTN, papilledema, cranial nerve dysfunction, abnormal motor) O - onset abrupt or w/ exertion, "thunderclap" h/a = subarachnoid hemorrhage; onset of h/a with exertion = increased ICP O - onset age \> 50 or P - previous onset history = new onset; first h/a \> 30 years

Answer 180

Pressing, non-pulsatile pain Lasts 30 minutes to 7 days Mild to moderate intensity Usually bialteral F:M ration 5:4 More than one of the following suggests migraine and not tension: Nausea, photophobia, phonophobia

Answer 181

Lasts 4-72 hours Usually unilateral, occassionally bilateral Pulsating Moderate to severe Aggravation by normal activity such as walking During headache 1 or more of the following: Nausea and/or vomiting, photophobia, phonophobia F:M ration 3:1 Positive family hx in 70-90%

Answer 182

Migraine type h/a w/ or after aura Focal dysfunction of cerebral cortex or brain stemp causes 1 or \> aura sx developing over 4 minutes, or 2 or more sx occurs in succession Sx can include: feeling of dread/anxiety, unusual fatigue, nervousness, excitement, GI upset, visual or olfactory alteration No aura sx should last \> 1 h - if this occurs, consider alternate dx Positive family hx in 70-90%

Answer 183

H/a tends to occur daily in groups or clusters Lasts several weeks to months then disappears for months to years Usually occurs at characteristic times of year, at the same time of day Common time: 1 hour into sleep, "alarm clock" headache Pain awakens the person h/a often located behind 1 eye with a steady, intense ("hot poke in the eye") sensation Severe pain in a crescendo pattern lasting 15 min to 3 hours Suicide headache Most often with ipsilateral autonomic signs such as lacrimation, conjunctival injection, ptosis, and nasal stuffiness F:M ration 1:3 to 1:8 Family hx of cluster h/a 20%

Answer 184

Migraine (90% favor one side) Cluster

Answer 185

Highly effective, infrequently used Recognize and avoid triggers (chocolate, ETOH, certain cheeses, MSG, stress, perfume, too much or too little sleep, hunger, altered routine) Encourage regular exercise Attend to posture at workstation Use tinted lens to minimize glare and bright lights

Answer 186

NSAIDs, APAP, others Limit use to 2 tx days/week to avoid analgesic rebound h/a

Answer 187

Selective serotonin receptor agnosists Select ergot derivatives Migrainef specific Caution use in pregnancy, CVD, uncontrolled HTN d/t potential vascular effect Helpful in tension-type h/a that does not respond to analgesic tx Also used in tx of cluster h/a (as is high flow O2)

Answer 188

Beta-blockers (propranolol) TCAs (nortriptyline, amitriptyline) Antiepileptic (gabapentin, valproate, topiramate) Lithium (specific to cluster h/a) Nutritional supplements (butterbur, feverfew, coenzyme 10, Mg, riboflavin) = effective and recommended CCBs = relatively ineffective

Answer 189

Any or all of the following: Use of any product \> 3x/week 2 or \> migraines per month that produce disabling sx for 3\> days Poor sx relief from various abortive tx Presence of select concomitant medical condition including HTN, hemiplegic, or basilar migraine Goal: reduce h/a frequency and severity, allow h/a medications to be more effective in controlling h/a sx

Answer 190

Beyond scope Likely has dx that need to be supported/clarified by specialist (e.g. RA, SLE) Compex health condition for which input into ongoing care from a specialist is warranted (e.g. HF or angina pectoris to cardiologist) Failure to respond to standard, evidence-based care (e.g. pt w/ low back pain who has failed to respond to standard therapies and pain mgmt)

Answer 191

Reveals: Acute hemorrhage Chronic hemorrhage Edema, shift Atrophy Ventricular size **Emergent image to r/o bleed: _CT w/o contrast_**

Answer 192

Reveals: tumor, abscess

Answer 193

Soft tissue imaging typically needs abnormal CT before MRI is considered for head Reveals: Tumor, hemorrhage of days-weeks duration, carcinomatous meningitis, AV malformation, posterior fossa lesions Sometimes done first to look for brain mets

Answer 194

Migraines w/ aura = HIGH risk of STROKE on OCPs w/ estrogen

Answer 195

Autoimmune vasculitis that affects medium-large vessels as well as temporal artery Inflammation and swelling of arteries leads to decreased blood flow and assoc. sx Disease most commonly occurs 50-85 years of age F \> M **Clinical sx:** Tender/nodular pulseless vessel (usually temporal artery) accompanied by severe unilateral h/a 50% will have visual impairment (transient visual blurring, diplopia, eye pain, sudden loss of vision) CRP and ESR usually markedly elevated - order first **Definitive dx: temporal artery bx** Color duplex U/S can be used as an aleternative/complement bx **Tx:** High-dose systemic corticosteroids 1-2mg/kg/day until disese stabilized followed by careful reduction in dose and continued for 6 months to 2 years ASA can be used to reduce risk of stroke GI cytoprotection (PPI or misoprostol) should be provided to minimize adverse effects of long-term corticosteroid tx

Answer 196

SBP elevated but DBP is at/close to baseline

Answer 197

Riboflavin 500 mg Magnesium 250-350 mg for 6-8 weeks -- Mg - might loosen stools Riboflavin - glow urine

Answer 198

NSADs & Steroids risk for gastritis = PPI minimize bone resorption = add low-dose biphosphonate Use opioid analgesics as needed Refer to neurosurgery for bx and neuro for mgmt

Answer 199

Jaw claudification in GCA

Answer 200

sour cream, ripened cheeses, sausage, salami, pizza, MSG, Herring, any pickled/fermented, marinated food, yeast products chocolate, nuts, nut butters Broad beans, lima beans, fava beans, snow peas, onions Citrus fruits, Bananas, caffeinated beverages, ETOH, aspartame/phenylalanine

Answer 201

Menses, ovulation, pregnancy Illness of any kind Intense/strenuous activity or exercise Altered sleep Altered eating patterns Bright/flickering lights Odors, fragrances, tobacco smoke weather, seasonal allergies Excessive/repetitive noises High altitudes Medications (SSRI, SNRI, other psych meds, analgesic overuse, hormonal contraception, hormonal tx post menopause) Stress or stress letdown

Answer 202

Typical sx of heartburn/regurg H. pylori screening not recommended in typical GERD Upper endoscopy not required in typical GERD sx

Answer 203

Alarm findings: dysphagia, odynophagia, unintended weight loss, hematemesis, black or blood stools, chest pain, choking Repeat endoscopy not indicated in patients w/o Barrett's esophagus in the absence of new sx

Answer 204

Empiric tx with PPI Protracted PPI use assoc w/ B12, Ca, Mg, Fe malabsorption, possible increased fracture and C-diff associated diarrhea risk If no response to PPI - refer for evaluatiion Weight loss if overweight Elevate head of bed 3-4" blocks 2-3 hours Avoid meals within 2-3 hours of bedtime Lowest effective dose if long-term including on-demand and intermittent tx H2RAs can be used as maintenance in pts w/o erosive disease 8-week PPI course = tx of choice in healing erosive esophagitis **PPI tx should be once-a-day, before first meal of day (traditional release PPIs such as omeprazole = 30-60 minutes before meal)** **May use twice-daily doising/adjust dose timeing if sx are nocturnal or variable schedule** **No major differences between different PPIs** **Maintenance PPI tx for pts w/ sx after PPI is dicontinued or in pts with complications such as erosive esophagitis and Barrett's**

Answer 205

95% of all **duodenal** ulcers = H. pylori

Answer 206

Elevated in Bacterial infection NL :

Answer 207

Elevated in Viral infection NL:

Answer 208

Elevated in Debris removal Good sign during recovery after illness NL :

Answer 209

Elevated in Allergens, parasites ("worms, wheezes, and weird diseases") NL:

Answer 210

elevated in Anaphylaxis, not fully understood NL:

Answer 211

LATE peritoneal sign Deep palpate area of abd tenderness Pain upon release = peritoneal inflammation AKA: rebound tenderness

Answer 212

Stand on tiptoes, then let bodyweight fall quickly onto heels Positive = abd pain increases and localizes Indicative of peritoneal inflammation In kids: "show me how you hop"

Answer 213

Painful arrest of inspiration triggered by palpating edge of inflamed gallbladder

Answer 214

Acute Pancreatitis "Boring epigastric pain to the back" ETOH use

Answer 215

Acute Diverticulitis - Cover for anaerobes and gram negative bacteria: Cipro + Flagyl

Answer 216

Duodenal ulcer - Check for H. Pylori RELIEF w/ FOOD

Answer 217

Erosive gastritis - D/C NSAIDs May check H. Pylori WORSE w/ FOOD

Answer 218

Inflammatory Bowel Disease - TOXIC MEGACOLON - anemia, leukocytosis w/ neutrophilia Need hospital admission

Answer 219

Hx of chronic pancreatitis Tobacco use DM

Answer 220

Blood transfusion Vertical transmission (mom to nursing infant) = uncommon

Answer 221

Mom to nursing infant

Answer 222

Person to person e.g. sexual contact

Answer 223

Fecal-oral

Answer 224

Hep B surface antigen + = HBV is present

Answer 225

Anti-Hep B core = ongoing Hep B infection

Answer 226

ALT \> AST Acute hep B infection = markedly elevated LFTs

Answer 227

ingestion of fecal matter via close person to person contact w/ infected person Sexual contact w/ infected person Ingestion of contaminated food/drinks

Answer 228

travelers to regions w/ intermediate/high rates of hep A Sex contacts of infected persons household members or caregivers of infected persons Household members or caregivers of infected persons Men who have sex w/ men user of certain illegal drugs persons w/ clotting factor disorders

Answer 229

15 to 50 days Avg: 28 days

Answer 230

fever, fatigue, loss of appetite, N&V, abdominal pain, gray-colored BMs, Joint pain, jaundice

Answer 231

None Most recover w/ no lasting liver damage Rarely fatal No chronic disease

Answer 232

IgM anti-HAV

Answer 233

Contact w/ infectious blood, semen, body fluids birth to infected mother sexual contact w/ infected person sharing of contaminated needles, syringes or other injection drug equipment Needlesticks or other sharp instrument injuries

Answer 234

infants born to infected mothers sex partners of infected persons multiple sex partners STDs Men who have sex w/ men Injection drug users household contacts of infected persons Health care and public safety workers exposed to blood hemodialysis patients Residents and staff of facilities for developmentally disabled persons Travelers to regions with intermediate or high rates of Hep B

Answer 235

45 to 160 days avg: 120 days

Answer 236

\> 90% of infants 25-50% of children 1-5 years 6-10% older children and adults Most persons recover from actue disease w/ no lasting liver damage Acute illness rarely fatal

Answer 237

HBsAg in acute AND chronic + IgM anti-HBc + in acute infection only

Answer 238

Contact w/ infectious blood sharing of contaminated needles, equipment LESS commonly through: sexual contact birth to an infected mother needlestick or other sharp instrument injuries

Answer 239

curren or former injection drug user recipient of clotting factor concentrates before 1987 recipients of blood transfusions before July 1992 Long-term hemodialysis Persons w/ known exposures to HCV HIV infected Infants born to infected mothers

Answer 240

14 to 180 days avg: 45 days

Answer 241

75-85% of newly infected persons will develop chronic infection 15-25% will clear virus

Answer 242

Uncommon Those who do develop acute illness recover w/ no lasting liver damage No serologic marker for acute infection

Answer 243

60-70% of chronically infected patients will develop chronic liver disease 5-20% develop cirrhosis over a period of 20-30 years 1-5% will die from cirrhosis of liver ca

Answer 244

HBsAg also positive in acute infection and additional markers as needed IgM + in acute infection ONLY

Answer 245

Screening assay (EIA or CIA) for anti-HCV Verify by more specific assay (NAT for HCV RNA)

Answer 246

All pregnant women Unvaccinated Born to endemic regions Infants born to HBsAg positive mothers Injection drug users Men who have sex w/ men Patients with elevated LFTs Hemodialysis patients HIV infected patients Donors of blood, plasma, organs, tissues or semen

Answer 247

Persons born from 1945-1965 Person who currently inject drugs or in the past Recipients of clotting factor concentrates before 1987 Recipients of blood or donated organs before July 1992 Long-term hemodialysis Known exposure HIV Born to infected mothers - do not test before age 18 months Patient w/ s/s of liver disease (LFTs) Donors of blood, plasma, organs, tissues, or semen

Answer 248

2 doses 6 months apart Recommended for all children at age 1 year Travelers Men who have sex w/ men Clotting factor disorders

Answer 249

Infants and children: 3-4 doses over 6-18 month schedule Adult: 3 doses over a 6 month period Recommended for all infants at birth At risk populations

Answer 250

No medication available Supportive

Answer 251

Acute: no medication available, supportive Chronic: Regular monitoring for signs of liver disease progression, some patients treated w/ antivirals

Answer 252

Acute: Antivirals and supportive tx Chronic: Regular monitoring for s/s of liver disease progression, some patients treated w/ antivirals Interferon alfa or peginterferon can be considered if HCV RNA has not cleared from serum in 3-4 months If HCV RNA has not cleared after 3 months of tx, ribavirin can be added - some authorities starting ribavirin w/ peginterferon from start Most patients recover in 3-6 months

Answer 253

Clinical **Abdominal discomfort or pain that has 2 of the following:** **Relieved with defecation** **Onset associated w/ change in frequency of stool** **Onset associated w/ change in appearance of stool** Other sx: abnormal stool frequency, abnormal stool form, abnormal stool passage, passage of mucus, bloating or abdominal distention, other somatic or psychological complaints common 2/3 are women

Answer 254

**Antispasmodics (anticholinergic) agents:** Dicyclomine 10-20 mg 3-4x/day Hyoscamine 0.125 mg 4x/day **Antidiarrheals:** Loperamide 2 mg 3-4x/day Cholestyramine 2-4 g orally with meals - Fiber supplementation - may cause increased bloating Osmotic laxatives TCAs - Notriptyline 10 mg orally at bedtime, increase to 25-50 mg at bedtime as tolerated Alternative - Trazodone 50 mg at bedtime

Answer 255

IBD Affects colon only - idiopathic inflammatory condition mucosal surface of colon More common in non-smokers and former smokers - severity may worsen in patients who stop smoking **Essentials for dx:** Bloody diarrhea Lower abd cramps and fecal urgency Negative stool cultures Anemia - low serum albumin Sigmoidoscopy key to dx Clinical findings: Bright red blood on DRE Tenesmus

Answer 256

Colonic dilation of \> 6 cm on radiographs w/ signs of toxicity Occurring in Heightens risk of perforation **(Ulcerative Colitis)**

Answer 257

Sigmoidoscopy establishes diagnosis Colonoscopy should not be done in fulminant disease d/t risk of perforation; perform after improvement to determine extend of disease Stool cultures (-) HCT, ESR, serum albumin

Answer 258

**Mild to moderate** Oral 5-ASA (mesalamine, balsalazide, sulfasalazine) - best for tx of diseases extending past sigmoid colon. Sx improvement in 50-75% of patients Mesalamine 2.4-4.8 g/day; improvement in 3-6 weeks, some require 2-3 months Sulfasalazine - low cost but higher side effects - start at 500 mg BID gradually increase over 1-2 weeks to 2 g BID Folic acid 1 mg once daily should be given to all patients taking sulfasalazine Corticosteroids to patients who do not improve within 4 weeks of 5-ASA tx Do not use antidiarrheals during acute phase of illness, useful at night time when taken prophylactically in pts w/o access to toilet - May use mesalamine rectal suppositories 1000 mg once daily for proctitis, 4 g per rectum at bedtime for proctosigmoiditis for 3-12 weeks = 75% will improve

Answer 259

colon ca occurs in 0.5-1% of patients per year of patients who have had colitis for \> 10 years folic acid 1 mg daily decreases risk of colon cancer colonoscopuyevery 1-2 years in patients w/ extensive colitis, beginning 8-10 years after dx

Answer 260

**Moderate to severe:** Corticosteroid improves 50-75% Prednisone 40-60 mg daily for 1-2 weeks, taper by 5-10 mg per week **Severe:** 48-64 mg IV or hydrocortisone 300 mg IV in four divided doses or by continuous infusion Infliximab 5 mg/kg IV Discontinue all PO intake Avoid opioid and anticholinergics Restore circulating volume w/ fluids/blood Correct electrolytes **Fulminant colitis and toxic megacolon:** NG suction, roll patients from side to side on the abdomen Serial abd radiographs to look for worsening dilation

Answer 261

Essentials for dx: Insidiuous onset Intermittent bouts of low-grade fever, diarrhea, RLQ pain RLQ mass and tenderness Perianal disease w/ abscess/fistulas Radiographic or endoscopic evidence ofulceration, stricturing, or fistuals in the small intestine or colon 1/3 of patients will have perianal disease Smokers are at increased risk Transmural disease might involve any of the GI tract

Answer 262

CBC, ESR, CRP Anemia may be d/t chronic inflammation, blood loss, iron deficiency, or B12 malabsorption Leukocytosis occurs in abscesses Obtain stool cultures barium upper GI series w/ small bowel follow through capsuled video imagin of small intestines CT eneterography colonoscopy Biopsy of intestine reveals granulomas in 25%

Answer 263

postprandial bloating, cramping pains, loud borborygmi Narrowing small bowel may occur as a result of inflammation, spasm, or fibrotic stenosis

Answer 264

Antidiarrheal agents Loperamide 2-4 mg 4x daily PRN, do not use in active severe colitis Broad spectrum abx if bacterial overgrowth Cholestyramine 2-4 g 1-2x/day before meals to bind the malabsorbed bile salts Similar tx to UC (mesalamine, prednisone, cipro+flagyl)

Answer 265

**If H pylori:** Omeprazole 20 mg bid Clarithromycin 500 mg bid Amoxicillin 1 gm bid x 14 days. **If resistance:** Omeprazole 20 mg bid Bismuth salicylate 2 tabs qid Tetracycline hcl 500 mg qid Flagyl 500 mg qid x 14 days.

Answer 266

Acute abd pain and fever LLQ tenderness and mass Leukocytosis **s/s** mild to moderate abd pain, aching usually LLQ Constipation or loose stools low-grade fever N&V Palpable LLQ mass Peritoneal signs in pts w/ free perforation

Answer 267

Upper endoscopy w/ gastric biopsy for H. pylori is diagnostic

Answer 268

Clear liquid diet Broad spectrum oral abx with anaerobic activity Augmentin 875/125 BID or Flagyl 500 mg TID + Cipro 500 mg BID OR Bactrim DS BID x 7-10 days

Answer 269

NPO IV fluids NG suction if ileus **IV abx** monotx with 2nd generation ceph (cefoxitin), piperacillin-tazobactam, or ticarcillin clavulanate OR combo tx with flagyl/clinda + aminoglyside/3rd generation ceph x 7-10 days

Answer 270

High fiber diet

Answer 271

severe pain or inability to tolerate oral intake s/s of sepsis/peritonitis CT scan showing signs of complicated disease (abscess, perforation) Failure to improve with outpatient mgmt Immunocompromised or frail, elderly patient

Answer 272

Fecal antigen or urea breath tests PPIs may cause false negative urea breath/fecal antigen tests and should be held for at least 7 days before serology testing not recommended for patients w/ low pre-test probability, cannot differentiate between current/past infections

Answer 273

2-6x higher risk for gastric cancer in presence of H. pylori 90% of gastric adenocarcinoma of stomach have positive H. pylori

Answer 274

Best auscultated w/ diaphragm Lower border of the right scapula Systolic murmur High pitched murmur

Answer 275

Ideal body weight used even in presence of obesity 75-125 mcg of levothyroxine or about 1.6 mcg/kg daily Elderly: 75% of adult needs

Answer 276

"Rule of odds" 7 oz 1 x 3 x 5 inches located between ribs 9 and 11 - \> 50% of patients with IM will develop splenomegaly Risk of splenic rupture greates in the 2nd and 3rd weeks of illness Risk continues for at least 1 month after symptoms resolve Prudent to get U/S to ensure resolution of splenomegaly

Answer 277

scallops, mussels organ meats and game meats beans spinach asparagus oatmeal baker's and brewer's yeasts

Answer 278

Hx of infectious endocarditis = increased risk of infectious endocarditis assoc. w/ dental procedure **Prophylaxis:** Clindamycin 600 mg Cephalexin 2g Azithromycin 500 mg Clarithromycin 500 mg all 30-60 minutes before procedure

Answer 279

Dysphagia Odynophagia (painful swallowing) GI bleed Unexplained weight loss Persistent chest pain

Answer 280

Pleocytosis (WBC \> 5 cells/mm in CSF) - found in infectious meningitis (viral, bacterial, fungal or protozoan) **Bacterial meningitis:** CSF glucose decreased (normal level 40% of plasma) CSF protein elevated Elevated CSF opening pressure

Answer 281

Normal CSF glucose level Modest elevation in CSF protein

Answer 282

pain may be minimal, but usually surrounded by areas of painful first and second degree burns white and leathery

Answer 283

Raw and moist Painful

Answer 284

**Tobacco use** Other risk fx: DM, HTN, HL

Answer 285

_Aggressive rehydration_ w/ careful monitoring d/t risk of pulmonary edema from reduced CO _Hyperkalemia_ is common d/t release of CK w/ tissue damage Rapid body cooling is _discouraged_ as this can stimulate cutaneous vasoconstriction inhibiting heat loss

Answer 286

Adequate pain control with IV morphine if nitroglycerin not immediately effective or if pulmonary congestion or severe agitation are present ASA (160-325 mg) chewable, nonenteric should be given as soon as possible and continued indefinitely in patients who can tolerate it Supplemental O2 in patients in respiratory distress or cyanosis Beta-blocker should be given if no contraindications exist, with first dose IV

Answer 287

Potent vasodilators Little to no negative effect on cardiac contractility/conduction Short acting - Nifedipine Long-acting w/ no cardiac depressant activity - Amlodipine Side effects: Headaches, dizziness, lightheadedness, flushing, and peripheral edema d/t vasodilation

Answer 288

Verapamil, Diltiazem Less potent vasodilators but have greater depressive effect on cardiac conduction and contractility compared to dihydropyridines Contraindicated in patients who are taking beta-blockers, severe HF, sick sinus syndrome, and 2nd or 3rd degree AV block

Answer 289

More specific and sensitive than EKG in diagnosing non-Q-wave MI More specific and sensitive than CK-MB in diagnosing unstable angina and non Q-wave MI Available quickly through rapid assay **Increases rapidly within the first 12 hours after MI and remains elevated for about 192 hours**

Answer 290

not as sensitive/specific as Troponin I in diagnosing unstable angina Increased within 6-12 hours of MI and begins to decrease in 24 to 48 hours, returns to normal in 60 hours

Answer 291

Tennis elbow Painful outer aspect of lower humerus Results from injury of extensor tendon at the lateral epicondyle Hand grip is often weak on affected side by elbow ROM is usually normal Counterforce brace worn to the back of the forearm can help relief symptoms

Answer 292

Strep pneumo (gram+) M. Pneumo (Atypical) C. Pneumo (Atypical) Respiratory viruses (Influenza A/B, RSV, adenovirus, parainfluenza) Inpatient Tx: All of the above Legionella sp. (Atypical) H. Influenze (gram -)

Answer 293

Streptococcus pneumoniae Gram + diplococci

Answer 294

**Non-resistant:** macrolides standard dose amox (1.5-2.5g/day) select cephs tetracyclines including doxy **DRSP** High dose amox (3-4g/day) Respiratory fluroquinolones

Answer 295

Viral load at time of infection is greatest risk factor in contracting HIV

Answer 296

mild h/a, nausea, insomnia, restlessness, agitation Typically dose related and will resolve within 2 weeks Eat small bites when nauseous APAP for h/a Change drug classes if sx too distracting/bothersome

Answer 297

Approved starting age 50 Recommended officially at age 60 Contains significantly more virus than the chickenpox vaccine Contains 14x the number of plaque-forming units of virus than the varicella vaccine

Answer 298

Routine screening for hypothyroidism is not performed during pregnancy ACOD recommendes screening if women has personal hx of hypothyroidism, famil hx, or is symptomatic ACOG also recommends screening if another disease is present assoc. w/ thyroid dysfunction (e.g. gestational DM)

Answer 299

All quinolones have potential to produce QT prolongation Prescribe w/ caution in older adults

Answer 300

**Hesselbach's triangle** forms the landmark for **direct inguinal hernia** The _inguinal ligament,_ _rectus muscle,_ and _epigastric vessels_ form the triangle Most common groin hernias in men and women Inguinal surgical repair is themost common procedure performed in the US

Answer 301

sunlight sensitivity

Answer 302

Internal inguinal ring Can occur in men and women Most are probably congenital, sx may not be obvious until later in life Indirect hernias are more common on the right side

Answer 303

Ultrasound of scrotum Ddx: inguinal hernia, hydrocele, varicocele U/S will yield quick, relaible information w/ dx accuracy of 93% for groin problems

Answer 304

Pts w/ audible carotid bruit are more likely to die from cardiovascular disease than cerebrovascular disease Poor predictor of carotid artery stenosis or stroke risk In pts w/ significant carotid artery stenosis, only 50% have an audible carotid bruit Value is that it is a good marker of generalized atherosclerosis Other vessels should be evaluated

Answer 305

Amlodipine - long acting CCB Dihydropyridines -- Thiazides are not potent enough and effect is not additive when combined with CCBs

Answer 306

Potassium level in 1 week ACEIs work in the kidney - can impair renal excretion of potassium esp in kidney impairment Common practice - monitor K, BUN, Cr 1 week after initiation of ACEI and w/ increase of dosage in a patient w/ HF and who receives an ACEI

Answer 307

MRI w/o contrast - provides info about soft tissues, like the lumbar discs Use contrast if patient has had hx of previous back surgery - contrast would be helpful to distinguish scar tissue from discs

Answer 308

Gram-negative bacillus 30% produce beta-lacatamase **Effective abx:** Cephalosporins Augmentin Macrolides Resp. fluoroquinolones tetracyclines including doxy

Answer 309

H. Influenzae (gram -)

Answer 310

atypical = not revelaed by gram stain **Effective abx:** Macrolides Respiratory fluoroquinolone Tetracycline inluding doxy **Ineffective:** beta-lactams (PCNs, cephs) beta-lactams are not effective as they work by destroying cell-wall - does not work w/ atypicals

Answer 311

M. Pneumo and C. Pneumo Largely cough transmitted Often seen in people who have recently spent extended time in close proximity long incubation period (3 weeks)

Answer 312

Not revealed by gram stain Transmission by inhaling mist or aspirating liquid that comes from infected water source No evidence of person-to-person spread of disease **Effective abx:** Macrolide Resp. fluoroquinolone Tetracyclines including doxy **Ineffective:** beta-lactams

Answer 313

Absence seizure Blank stare 3-50 seconds w/ impaired level of consciousness Usual age of onset 3-15 years

Answer 314

awake or momentary loss of cosciousness with abnormal motor behavior lasting seconds to minutes one or more muscle groups causes brief jerking contractions of the limbs and trunk, occiassional flinging the patient

Answer 315

aka jacksonian seizures awake state w/ abnormal motor, sensory, autonomic, or psychic behavior movement can affect any part of body, localized or generalized

Answer 316

accompanied by an aura (unusual sense of smell, taste, visual or auditory hallucinations, or stomach upset) followed by a vague stare and facial movements, muscle contractions/relaxation, autonomic signs Can progress to loss of consciousness

Answer 317

Act as cushions between tendons and bones body contains more than 150 bursa fluid-filled sacs lined by synovial tissue, which produces fluid that lubricates and reduces friction between tendons and bones

Answer 318

Minimizes sx of Parkinson disease Tends to be less effective w/ more adverse effects as disease progresses Most patients who take Levodopa for more than 5-10 years develop dyskinesia

Answer 319

Thiazide diuretics Niacin ASA Cyclosporine ETOH

Answer 320

Conditions w/ increased catabolism and turnover e.g. psoriasis chronic hemolytic anemia Conditions w/ decreased renal uric acid clearance: e.g. intrinsic kidney disease and renal failure

Answer 321

Last US case 1949 Last worldwide case 1970s Caused by variola virus Most contagious w/ onset of rash Infected person remains contagious until last small pox scab falls off

Answer 322

pH: 2 Production: 1-2 mEq/hour in resting increases to 30-50 mEq/hour after a meal

Answer 323

CBC w/ diff CXR Additional testing based on patient presentation and comorbidity

Answer 324

Strep pneumo low DSRP risk Low risk of H. influenzae Atypical pathogens (M. pneumo, C. pneumo) Resp viruses (influenza A/B, adenovirus, RSV, parainfluenza) Tx: Macrolide or Doxy will cover non-DSRP and atypicals

Answer 325

Strep pneumo w/ DRSP risk H. influenzae (gram -) Atypicals (M. pneumo, C. pneumo, Legionella) Resp viruses **Tx:** Respiratory fluroquinolone (moxi, gemi, levo) **OR** Advanced macrolide or Doxy + beta lactam such as high dose amox (3-4g/day), HD amox-clav, Ceftriaxone, cefpodoxime (vantin), cefuroxime (ceftin)

Answer 326

Erythromycin Clarithromycin - Erythro - limited gram neg coverage, poor tolerance d/t GI adverse effects

Answer 327

wide = Good circulating fluid volume narrow = dehydration

Answer 328

In gero - tachypnea Strep pneumo and Legionella = most likely to result in pleuritic chest pain Consolidation - dullness to percussion, increased tactile fremitus (increased w/ increased tissue density) Bronchial or tubular breath sounds often w/ late inspiratory crackles that do not clear w/ cough Expect 4-6 weeks minimum of continued abnormal breath/lung findings even w/ successful tx

Answer 329

Associated w/ pneumonia, less commonly w/ PE (would be a late finding in PE) Sharp, localized pain (pt can pinpoint), worse w/ deep breath, movement, cough Audible pleural friction rub, from movement of inflamed pelura layers - sound similar to stepping into fresh snow - may be both during inspiration and expiration

Answer 330

Respiratory tract viruses 90% Bacteria - M. Pneumo, C. Pneumo, B. pertussis 10%

Answer 331

Anticholinergic bronchodilatero (Atrovent) Inhaled beta-agonist (Albuterol) short course of oral corticosteroids - Prednisone 40 mg orally daily x 3-5 days - addresses lower airway inflammation, cheapest, and most effective Consider use of macrolide of tetracycline when abx indicated

Answer 332

Common chronic disorder of the aiways Variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation Inflamamtion causes the bronchospasm

Answer 333

Recurrent cough, wheeze, SOB, and/or chest tightness s/sx occur or worsen at night, or with exercise, viral respiratory infections, aeroallergens, and/or pulmonary irritants (e.g. second hand smoke) **Spirometry needed to make dx of asthma** **Peak flow meter is used for monitoring** Airflow obstruction that _is at least partially reversible_: Increase in FEV1 12% or \> from baseline post SABA use

Answer 334

well-controlled: 3-6 months not well-controlled: 2-6 weeks

Answer 335

Mometasone, Fluticasone (Flovent), Budesonide (Pulmicort), Beclomethasone (QVAR), Ciclesonide Preferred controlled tx for persistent asthma Requires consistent daily use for optimal effect Prevents inflammation Helps stop at least 8 inflammatory mediators - Most PCPs are NOT well-versed in the relative potency of ICS and prescribe an appropriate dose for the patient's clinical presentation

Answer 336

Symbicort, Advair, Dulera Preferred tx for moderate and severe persistent asthma Increased death in asthma pts using LABA ICS w/ LABA should NOT be used in pts whose asthma is well-controlled with an ICS alone

Answer 337

Montelukast (Singulair) Zafirlukast (Accolate) Additional benefit w/ _allergic rhinitis_, most often used _in conjunction_ with ICS not useful as solo therapy

Answer 338

20% of a relatively small dose in ICS

Answer 339

ICS at least 2-3x more potent than LTRAs LTRAs only prevents Leukotriene whereas ICS prevents at least 8 inflammatory mediators

Answer 340

acute reliever for acute bronchospasm muscle relaxer = zero antiinflammatory effect Albuterol (proventil), salbutamol, pirbuterol, levalbuterol (Xopenex) **Up to 3 tx at 20 minute intervals as needed** All asthma pts should have ready access Drug of choice for preventing exercise-induced bronchospasm (EIB) - 2 puffs 30 minutes before exercise Use of \> 2 days/week (except for exercise) = poor inflammatory control

Answer 341

1. Make sure canister fits firmly in actuator 2. Shake inhaler well 3. take cap off mouthpiece, look inside for foreign objects, take out if any 4. Hold inhaler w/ mouthpiece down 5. Breath out 6. Put mouthpiece around mouth and close lips around it 7. Push canister all the way down while breathing deeply and slowly through mouth 8. Hold breath for about 10 seconds 9. Breath out as lowsly as long as you can 10. If more sprays are prescribed, **wait 1 minute, shake inhaler again** 11. Put cap back on mouthpiece, snap firmly into place -- Clean inhaler at least once a week Store w/ mouthpiece pointing down Prime inhaler - shake and point away from face x 4 Prime if first time, not used for 14 days, or if it is dropped -- How to clean 1. Take canister out of actuator, take cap off 2. Hold actuator under faucet and run warm water through it x 30 seconds 3. Turn the actuator upside down and run water through mouthpiece x 30 seconds 4. Shake off as much water from the actuator 5. Let actuator air-dry overnight 6. when dry, shake well again and spray once before using

Answer 342

Aggressive tx of inflammaiton during asthma flare e.g. Prednisone 40-60 mg/day x 3-10 days Taper usually not needed w/ the dose and duration During asthma flare, increase use of rescue drug

Answer 343

Viral respiratory infection Typically 5-7 days viral infection would clear

Answer 344

Bronchodilator via blockage of cholinergic receptors aka Muscarinic Antagonist Emerging role in asthma tx Well-established in COPD Used primarily for prevention, not tx, of bronchospasm Atrovent - ipratropium bromide - SAMA Spiriva - Tiotropium bromide - LAMA

Answer 345

mild to moderate bronchodilator cheap but requires blood draws for monitoring multiple drug-drug interaction potential

Answer 346

sx 2d/week or less nighttime awakening 2x/month or less SABA use 2d/week or less No interference w/ normal activity Normal FEV1 between exacerbations FEV1 \> 80% predicted FEV1/FVC normal

Answer 347

sx \> 2 days/week but not daily Nighttime awakening 3-4x/month SABA \> 2days/week but not daily Minor activity limitation FEV1 \> 80% predicted FEV1/FVC normal

Answer 348

Daily sx Nighttime awakening \> 1x/week but not nightly SABA daily Some limitation w/ activity FEV1 \> 60 but FEV1/FVC reduced by 5% Step 3 tx, consider short course of oral corticosteroids

Answer 349

sx throughout day nighttime awakenings often 7x/week SABA several times/day Extreme activity limitation FEV1 FEV1/FVC reduced \> 5% Step 4 tx + consider oral corticosteroids

Answer 350

Intermittent asthma SABA PRN

Answer 351

Mild persistent **Low dose ICS** + SABA PRN alternatives: Cromolyn, LTRA, nedocromil, thophylline

Answer 352

Moderate persistent Low-dose ICS + LABA or Medium dose ICS Alternative: low-dose ICS+LTRA/theophylline/Zileuton

Answer 353

Severe persistent Medium dose ICS + LABA Alternative: Medium-dose ICS + LTRA/theophylline/Zileuton

Answer 354

High dose ICS + LABA AND Omalizumab for patients who have allergies

Answer 355

High dose ICS + LABA + oral corticosteroids AND consider Omalizumab for patient who have allergies

Answer 356

Step Up if needed - first, check adherence, environmental control, and comorbid conditions Step Down - if possible and asthma is well controlled at least 3 months

Answer 357

e.g. asthma, COPD Hyperresonance Decreased tactile fremitus = decreased tissue density Wheeze (expiratory first, inspiratory later) Low diaphragm Increased AP diameter ("barrel chest")

Answer 358

Preventable, treatable disease w/ significant extrapulmonary effects Pulmonary component is characterized by airflow limitation that is not fully reversible Usually progressive and associated w/ abnormal inflammatory response of lung to noxious particles or gasses Dx should be considered in any pt w/ progressive dyspnea, chronic cough, sputum production, and/or hx of exposure to risk fx (tobacco, pollution, occupational)

Answer 359

Spirometry is required for dx Use age-related variables to avoid over-dx FEV1:FVC Classification of severity determined by FEV1 - Alpha-1 antitrypsin deficiency screening - perform when COPD develops in pts of Caucasian descent under 45 or w/ strong family hx of COPD

Answer 360

long-standing COPD = high pulmonary artery pressures = right atrial and ventricular hypertrophy = atrial fib

Answer 361

GOLD 1 FEV1 \> 80% predicated

Answer 362

GOLD 2 FEV1 50-80%

Answer 363

Symptomatic FEV1 30-50% predicted

Answer 364

GOLD 4 Symptomatic FEV1

Answer 365

SABA prn for relief of bronchospasm LABA - protracted duration of bronchodilation, used on a daily set schedule LAMA - protracted duration of bronchodilation, minimized risk of COPD exac, used on a daily set schedule ICS - antiinflammatory, minimized risk of COPD exac, used on a daily set schedule Theophylline - bronchodilator, used on a daily set schedule PDE-4 inhibitor (roflumilast) - minimized risk of COPD exac, used on a daily set schedule

Answer 366

First choice: SAMA or SABA prn -- SAMA: Atrovent SABA: Proventil Second choice: LAMA, LABA or combined SAMA+SABA Alternative: Theophylline

Answer 367

LAMA or LABA 2nd choice: LAMA + LABA Alternative: PDE-4 inhibitor, SABA and/or SAMA, Theophylline (do not use w/ roflumilast)

Answer 368

ICS + LABA or LAMA 2nd choice: ICS+LAMA, ICS+LABA+LAMA, ICS+LABA+PDE4 inhibitor etc. Alternative: Carbocysteine (mucolytic) SABA and/or SAMA, theophylline

Answer 369

Do not use with PDE4 inhibitor roflumilast

Answer 370

O2 delivery to organs, baseline PaO2 at rest to 60 mmHg at sea level or higher and/or SaO2 90% or higher **Indications for O2 therapy in COPD** PaO2 PaO2 55-59 mmHg or SaO2 = 89% in the presence of cor pulmonale, right heart failure, or polycythemia (HCT \> 56%)

Answer 371

Event in the natural course of disease Change in the patient's baseline dyspnea, cough, and/or sputum beyond day to day variability sufficient to warrant change in mgmt

Answer 372

SABA and/or SAMA prn Consider adding LABA or LAMA if patient currently not using one **If baseline FEV1** Add systemic corticosteroid - Prednisone 40 mg/day x 5-10 days studies show shorter steroid courses equally effective as longer courses Consider adding ICS if not currently using Encourage smoking cessation = associated w/ reduction of COPD exac, and reduction in rate of lung function loss **Antibiotic therapy** LIkely indicated if 3 cardinal sx: **Increased dyspnea, increased sputum volume, and increased sputum purulence** CXR - only w/ fever and/or low SaO2 to r/o concomitant PNA

Answer 373

Macrolides

Answer 374

Respiratory fluoroquinolones

Answer 375

Causative pathogens in 30-50% include H. influenzae, H. parainfluenzae, S. pneumoniae, M. catarrhalis Less common: atypical, other gram+ and gram- organisms **Mild to moderate** Abx usually not indicated, if prescribed, consider: Amox - vulnerable to H. Flu and M. cat Doxy - first choice TMP-SMX - not as great H. flu coverage **Severe COPD exac** Consider: Amox-clav Cephalosporin (cefdinir, cefpodoxime, others) Azithromycin - risk for QT prolongation Clarithromycin - CYP450 inhibitor Fluoroquinolone w/ DRSP actibity (Moxi, Levo) - risk for tendon rupture

Answer 376

s/sx Low grade fever, nonproductive cough, nonspecific presentation Widened mediastinum d/t hemorrhage visile on CXR or thoracic CT Tx: Fluroquinolone Expert consult

Answer 377

Most common form pustular skin lesion that eventually forms ulcer w/ eschar tx: Fluoroquinolone expert consult

Answer 378

Atrovent If no relief add ICS if inadequate response, PO prednisone last line: codeine+dextromethorphan

Answer 379

Muscle paralyzing Food-borne Sx: double vision, blurred, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness, moves DOWN body, shoulders affected first Most recover - weeks to months Tx supportive care, antitoxin (CDC, California department of health)

Answer 380

Autoimmune process involving beta-cell destruction = insulin deficiency short history of significant sx: unexplained weight loss, ketonuria, polydipsia, polyphagia, polyuria usually dx in acute ill child or young adult

Answer 381

Insulin resistance w/ eventual insulin deficiency Few if any sx Usually dx during routine screening

Answer 382

All adults who are overweight BMI 25 or \> and have additional risk fx: physical inactivity First-degree relative with DM2 High-risk ethnicity Women w/ hx of giving birth to baby \> 9 lb or GDM Hx of GDM - screen women at 6-12 weeks postpartum HTN HDL 250 PCOS IFG or IGT on previous testing Clinical conditions assoc w/ insulin resistance (severe obesity, acanthosis nigricans) Hx of CVD -- In the absence of above criteria, begin screening at 45 years If normal, repeat every 3 years, more frequent depending on risk status

Answer 383

Fasting glucose 126 or \> Random glucose 200 or \> w/ sx 2h plasma glucose of 200 or \> after 75 g glucose load (most expensive) A1c 6.5 or \> Repeat A1C if asymptomatic adult with glucose 200 or Repeat not needed if sx or if glucose \> 200

Answer 384

IFG = 100 to 125 mg/dL IGT= 140 to 199 mg/dL on 75g OGTT A1C = 5.7 to 6.4

Answer 385

A1C Fasting 70-130 mg/dL Peak postprandial (1-2h after meal) Bedtime 90-150 mg/dL - A1C A1C - Obtain A1C at least twice a year in patients who are meeting tx goals and who have stable glycemic control A1C quarterly in pts whose therapy has changed or who are not meeting glycemic goals

Answer 386

6% = 126 7% = 154 8% = 183 12% = 298

Answer 387

Metformin Brand: Glucophage **Insulin sensitizer** No inherent hypoglycemia risk = minimal action on fasting and postprandial glucose **90% renally eliminated** **D/C at GFR** risk of **lactic acidosis** in impaired renal function/comorbidities/frailty add MVI - long-term use B12 malabsorption Anticipated A1C reduction 1-2% - **Radiocontrast use, surgery, or any potential to alter hydration status:** _omit Metformin for the day of and for at least 48 hours post study/procedure._ Reinitiate when baseline hydration/renal function are re-established

Answer 388

Pioglitazones (Actos), Rosiglitazone (Avandia) Anticipated A1c reduction 1-2% **Insulin sensitizer** No inherent hypoglycemic risk = minimal action on fasting/postprandial glucose Monitor ALT periodically, rare risk hepatic toxicity **Edema risk,** especially when used w/ insulin or SU **Can exacerbate HF** **Use w/ insulin or nitrates not recommended** Pioglitazone use (Actos) use \> 1 year possibly assoc. w/ **bladder ca**

Answer 389

Glipizide (Glucotrol), Glyburide (DiaBeta), Glimepiride (Amaryl) $4 list Anticipated A1C reduction 1-2% **Increases insulin release** **Hypoglycemia risk** esp. in elders, impaired renal function, nocturnal, fasting and 4-6h after meals Typically less effective after 5 years d/t failing beta cells May also be less effective in older adults, presence of severe hyperglycemia Glipizide preferred in elderly over Glyburide

Answer 390

Repaglinide (Prandin), Nateglinide (Starlix) Anticipated A1C redution 1-1.5% **Increases insulin release** **Hypoglycemia risk 2-3 h after medication**, action on postprandial glucose only **Take 1-30 minutes before meal** Results in quick **insulin burst w/ onset of action 20 minutes** after dose taken No additional benefit if used with SU Can e used in presence of severe sulfa allergy (no sulfa molecule) Use w/ caution in hepatic/renal impairment

Answer 391

Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), alogliptin (Nesina) Anticipated A1C reduction 0.6-1.4% **Increases insulin release** Minimal to no hypoglycemia risk = action largely on postprandial glucose **Adjust dose in renal impairment** Well tolerated Weight neutral Indicated to improve glycemic control _in combination_ w/ insulin sensitizers or other insulin releasers **Monitor for pancreatitis** after intitiation and dose increases Has not been studied in patients w/ hx of pancreatitis

Answer 392

Incretin mimetics Exenatide (Bydureon, Byetta), Ligralutide (Victoza) Anticipated A1C reduction 1-2% **Increases insulin release** Little inherent hypoglycemia risk **Slows gastric emptying, often leading to appetite suppression and weight loss** Stimulates insulin release in response to increased plasma glucose **Major side effect: N/V** better w/ dose adjustment, continued use **Contraindicated in gastroparesis** Adjunct use in DM2 when not adequately controlled with biguanide, SU Exenatide - not FDA approved as add-on tx w/ insulin glargine D/C if acute pancreatitis sx develop (persistent abd pain w/ vomiting) **Exenatide - do not use if hx of prancreatitis** **Do not prescribe if CrCl** Caution in CrCl 30-50 mL/min when increasing dose from 5-10 mcg

Answer 393

Acarbose (Precose), Miglitol (Glyset) Anticipated A1C reduction 0.3-0.9% **Delays intestinal carbohydrate absorption** by reducing postprandial digestion of starches and disaccharides via enzyme action inhibition **Little inhered hypoglycemia risk** **Taken with first bite of meal** Helpful in mgmt of postprandial hyperglycemia Does not enhance insulin secretion or sensitivity **GI adverse effect** - avoid use in IBS, impaired renal function Increased gas! - Carbs are broken down more slowly

Answer 394

Canagliflozin (Invokana), Dapagliflozin (Jardiance) Anticipated A1C reduction 0.7 - 1% Lowers plasma glucose levels by **increasing the amount of glucose excreted in urine** Hypoglycemic risk r/t glucose offload; increased when used w/ insulin and insulin secretagogues **Adverse effects = genital mycotic infection (10% in F, 5% in M), UTI, increased urination** Modest weight loss of 4-7 lbs **Dose adjustment or discontinuation required in renal impairment** d/t risk of adverse effects, electrolye imbalances, and less therapeutic effect Can be used as add-on tx w/ metformin, SU, and others

Answer 395

Type I - all pts at dx Type II At time of dx to help achieve initial glycemic control When 2 or more agents at optimized doses are inadequate to maintain glycemic control when acutely ill In critically ill pts type I or II - BG levels should be kept at 140-180 mg/dL

Answer 396

Short acting Onset 15-30 minutes Peak 30 minutes - 2.5 hr Duration 3-6.5 hr Give within 15 min or right after meals

Answer 397

Short acting Onset 10-20 minutes Give 5-10 minutes before meals Peak 1-3 hr Duration 3-5 hr

Answer 398

Short acting Onset 10-15 min give within 15 minutes or right after meals Peak 1-1.5 hr Duration 3-5 hr

Answer 399

Short acting Onset 30 min-1 hr Peak 2-3 hr Duration 4-6 hr

Answer 400

Intermediate acting Onset 1-2 hr Peak 6-14 hr Duration 16-24 hr

Answer 401

Long-acting Clinical effect 1 hr No peak Duration 24 hours

Answer 402

Long-acting Onset 1-2 hr Peak 6-8 hr (minimal) Dose dependent duration 12 hr at 0.2 units/kg 20 hr at 0.4 units/kg

Answer 403

Large waistline Hypercholesterolemia Low HDL High BP High glucose

Answer 404

Protrusion of the membranes that cover the spine and spinal cord itself through a defect in the bony encasement of the vertebral column

Answer 405

Protrusion of the spinal cord through a defect in the vertebral arch

Answer 406

abdominal wall defect intestines, liver, and occassionally other organs remain outside of the abdomen in a sac

Answer 407

Shoulder abduction

Answer 408

Daily ASA: 1-2 baby aspirins; Plavix 75 mg daily if ASA allergy in men \> 50 and women \> 60 w/ DM and 1 or more CVD risk fx (HTN, family hx, etc.) BP control to include ACEI or ARB Statin usually indicated; esp. for age \> 40 or w/ hx of ACS Check fasting lipid profile annnually Check serum creatinine, calculated GFR, urine microalbumin annually Limit trans and saturated fats 150 min/week of moderate activity, 30 min 5x/week, resistance exercise 3x/week Vigorous exercise potentially contraindicate in the presence of proliferative or severe nonproliferative retinopathy d/t risk of vitreous hemorrhage or retinal detachment Annual dilated eye exam minimum Visual foot exam every visit Comprehensive lower extremity sensory exam annually - 10g monofilament w/ 1 or more of the following: vibration using 128 Hz tunning fork, pinprick sensation, ankle reflexes, or vibration threshold Review goals periodically

Answer 409

**Defined as ANY 3 of the following:** **Waist circumference** Men \> 102 cm (\>40in) Women \> 88 cm (\>35 in) **Triglycerides ≥ 150 mg/dL** **HDL** Men Women **Blood Pressure ≥ 130/80 mmHg** **Fasting glucose ≥ 110 mg/dL**

Answer 410

Only increases when about 50% of renal function has been destroyed

Answer 411

microaneurysms, macular edema visual loss d/t macular edema

Answer 412

new fragile vessels form

Answer 413

New onset blurry vision "floaters" "holes" "swiss cheese" vision Tx tight BG control photocoagulation Vitrectomy if disease progresses after photocoagulation

Answer 414

Stroke, vascular (multi-infarct) dementia (20% of all dementias) Atherosclerosis, MI, LVH, HF HTN nephorpathy, renal failure HTN retinopathy w/ risk of blindness

Answer 415

Narrowing of terminal branches No vision change or permanent fidings

Answer 416

Narrowing of vessels w/ severe local constriction No vision change or permanent findings

Answer 417

Preceding signs w/ striate hemorrhages and soft exudates Potential for visual change and permanent findings Black spots in visual field pending HTN crisis - 911

Answer 418

Papilledema w/ preceding signs w/ striate hemorrhages and soft exudates Potential for visual change and permanent findings pending HTN crisis - 911

Answer 419

Maintain normal body weight SBP reduction **5-20 mmHg** per 10 kg weight loss

Answer 420

Rich in fruits and vegetables, low-fat dairy, reduced saturated and total fat ## Footnote **SBP reduction 8-14 mmHg**

Answer 421

## Footnote **SBP 2-8 mmHg reduction**

Answer 422

Decreases insulin resistance/increases insulin sensitivity Increases HDL and lowers TG Moderate to vigorous physical activity 40 min/day 3-4x/week No more than 48 hours w/o exercise (CVD benefit wears off) **SBP reduction 4-9 mmHg**

Answer 423

M F SBP reduction 2-4 mmHg

Answer 424

**60 y and older** **If DM goal Black: Initiate thiazide and/or CCB Nonblack: Initiate thiazide, ACEI/ARB, or CCB -- _CKD:_ Initiate ACEI/ARB _all races_ - may combine w/ other drug classes**

Answer 425

**After initiation, wait 1 month, if not at goal:** Reinforce medication and lifestyle changes Maximize medications **wait 1 month,** if still not at goal, titrate meds (maximize dose of first drug, add second drug, maximize second drug etc.) Reinforce medication and lifestyle changes **wait 1 month,** if still not at goal Reinforce medication and lifestyle changes Add addition medication class (beta-blocker, aldosterone antagonist) and/or refer to HCP w/ expertise in HTN mgmt

Answer 426

HCTZ, chlorthalidone MOA: low-volume sodium depletion = PVR reduction w/ high dose (e.g. HCTZ 25 mg/day) potential negative impact on HL, glucose control **Monitor for Na, K, Mg depletion** **Calcium sparing - monitor for hypercalcemia** Lower observed rate of fractures in women who are long-term thiazide users Less effective w/ advancing renal impairment, esp if GFR Loop diuretics remain effective w/ lower GFR Only use loop diuretics to off-load fluid, not for BP control

Answer 427

**ACEIs:** Lisino**_pril_**, Enela_pril_ (Vasotec) **ARBs:** Lo**_sartan_** (Cozaar), telmi**_sartan_** (Micardis) **Attenuates angiotensin II (potent vasoconstrictor that also stimulates catecholamine release)** ACEIs minimize production ARBs block its action - **Adjust dose in renal insufficiency** **Do not use in bilateral renal artery stenosis** Modest **hyperkalemia** risk, esp. w/ inadequate fluid intake, when used w/ aldosterone antagonist ACEI induced cough: can use ARB as an alternative Angiodema risk w/ ACEI use, less w/ ARB **Do not use in pregnancy (Category D)** Renally eliminated

Answer 428

MOA: causes vasodilation **Dihydropyridine (DHP):** Amlod**ipine** (Norvasc), felod**ipine** (Plendil) **Nondihydropyridine (non-DHP):** Diltiazem, verapamil Ankle edema particularly with DHPs **NonDHP: caution w/ BB and untreated heart block** **NonDHP: CYP450 3A4 inhibitor** Avoid use/use w/ caution in HF, renal, hepatic impairment

Answer 429

Atenolol, metropolol, propranolol MOA: Block adrenergic beta1 receptor sites, blunt catecholamine response Non-cardioselective BBs (propranolol, nadolol) also block beta2 receptor sites Use w/ caution in untreated heart block Lower dose cardioselective beta-blocker tx usually acceptable in COPD, asthma - monitor for worsening airway obstruction when discontinuing, taper dose over a 10-14 day period to allow previously blocked receptors to acclimate Ok to use BB if pt has pacer

Answer 430

Spironolactone (Aldactone), eplerenone (Inspra) MOA: Block effects of aldosterone, therefore better regulating of Na+ and water homeostasis and maintenance of intravascular volume Aldosterone = increases sodium reabsorption **Hyperkalemia risk,** particularly w/ ACEI/ARB, volume depletion, including excessive diuresis **Gynecomastia risk** w/ prolonged use (androgen blocker) Caution in renal impairment

Answer 431

Clonidine (catapres) Methyldopa (aldomet) - use in pregnancy w/ primary HTN category B/C MOA: works at brain BP control center Sedation risk Abrupt clonidine withdrawal = rebound HTN risk Not mentioned in JNC-8

Answer 432

No documented drug interactions Lowers BP in large doses Ok to use

Answer 433

Triglycerides

Answer 434

Solid at room temp Avoid tropical oils such as palm and coconut oil

Answer 435

Increase intake of plant sterols and stanols to 2g/day (Take Control and Benecol margarine) Viscous or soluble fiber to 10-25 g/day (oatmel, oat bran) OAT = best grain for fat and constipation

Answer 436

Reduce saturated fat to Avoid trans fats Reduce total cholesterol intake to Dietary fat to 25-25% of total daily caloric intake

Answer 437

Increase intake of omega-3 fatty acids (EPA and DHA) w/o CHD: oily fish 2x/week Include oils and food risk in a-linolenic acid (flaxseed, canola, soybean oils, walnuts) w/ CHD: 1 g of EPA+DHA/day preferably from oily fish (4 oz of salmon) EPA+DHA in consultation w/ HCP

Answer 438

**21-75 y/o** **and** clinical ASCVD **or** LDL 190 and higher If 40-75 y/o DM and 7.5% 10 year ASCVD risk = high dose statin tx If 7.5% or higher ASCVD risk, and 40-75y/o no DM = use moderate-to-high statin tx **High dose statin lowers LDL-C by approx. 50%**

Answer 439

indicated if \> 75 y/o with clinical ASCVD or DM 40-75 y/o LDL

Answer 440

**High dose LDL reduction 50%** Atorvastatin (Zocor) 40-80 mg daily Rosuvastatin (Crestor) 20-40 mg daily **Moderate dose LDL reduction 1/3 (30-49%)** Atorvastatin 10-20 mg daily Rosuvastatin 5-10 mg daily Simvastatin 20-40 mg daily Pravastatin 40-80 mg daily Lovastatin 40 mg daily ($4) **Low dose LDL reduction 1/4 (** Pravastatin 10-20 mg daily Lovastatin 20 mg daily

Answer 441

LDL reduction 18-55% HDL increase 5-15% TG decrease 7-30% Check baseline hepatic function DM2 risk slightly increased w/ statin use, esp at high dose, CVD benefit outweighs small risk Cognitive impairment rarely reported, if it occurs, lower dose or try another statin Caution w/ concomitant use of **grapefruit juice (intestinal CYP450 34A inhibitor)** w/ use of these **3 statins (simvastatin, atorvastatin, lovastatin)** **Adverse effects: rhabdo, myositis** - rare, most often noted w/ higher statin dose, or in combination w/ fibrate, renal impairment, multiple comorbidities, low body weight, advanced age Do not use simvastatin at 80 mg dose d/t rhabdo risk

Answer 442

intestinal CYP450 34A inhibitor caution w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)

Answer 443

E.g. Cholestyramine (Questran), colestipol (Colestid), colesevelam (WelChol) LDL reduction 15-30% HDL increase 3-5% TG increase if 400 or \> Thickens stool! Nonsystemic w/ no hepatic monitoring required minimal effect on TG untill 400 and \> Adverse effects: **GI distress,** constipation, decreased absorption of other drugs if resin taken within 2 hours of many medications

Answer 444

E.g. Ezetimibe (Zetia) LDL decreases 15-20% HDL increases 3-5% Minimal effect on TG Most often prescribed w/ another agent such as a statin Adverse effects: few d/t limited systemic absorption No dose adjustment in renal/hepatic absorption (Vytorin) - ezetimibe combined w/ simvastatin

Answer 445

E.g. Niaspan, generic niacin HDL increases 15-35% **TG decreases 20-50%** LDL decreases 5-25% Particularly effective against highly atherogenic LDL lipoprotein (a) Adverse effects: **Flushing** (take ASA 325 1 hour before dose), hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity (rare) **Contraindication:** active liver disease, severe gout, peptic ulcer

Answer 446

E.g. Gemfibrozil (Lopid), fenofibrate (TriCor), fenofibric acid (Trilipix) HDL increases 10-20% **TG decreases 20-50%** LDL decreases 5-20% Adverse effects: dyspepsia, gallstones, myopathy, including rhabdomyolysis if taken w/ statin _Fenofibric acid_ the only fibrate FDA labeled for use w/ statin but still carries the myositis warning **Contraindicated** in severe renal or hepatic disease

Answer 447

**At 4g/dose:** TG decreases 20-30% Increases HDL 1-5% 4g = 1 lb of salmon/day Adverse effects: **Increased risk of bleeding d/t modest antiplatelet effect**, GI upset, fishy taste (can be minimized by freezing capsules, taking w/ food, avoiding hot beverages immediately post ingestion)

Answer 448

Class I = no sx Class II = sx w/ moderate activity Class IIIa = sx w/ ordinary activity Class IIIb = sx w/ minimal activity Class IV = sx at rest w/ no activity

Answer 449

No sx Tx: primary prevention, treat risk factors

Answer 450

Sx w/ moderate activity Tx: Add ACE/ARB and BB if not already taking

Answer 451

Class IIIa = Sx w/ ordinary activity Class IIIb = sx w/ minimal activity Tx: Add diuretics, Digoxin, Nitrates, Hydralazine Consider biventricular pacing and implantable defibrillator

Answer 452

Sx at rest, w/ no activity Tx: Hospice, heart transplant, chronic inotropes (Dobutamine clinic), permanent pump (LVAD)

Answer 453

At high risk for HF but w/o structural heart disease or sx of HF e.g. HTN, atherosclerotic heart disease, DM, obesity, metabolic syndrome or pts using cardiotoxins, family hx of cardiomyopathy Tx: ACEI or ARB for vascular disease or DM Statins as appropriate

Answer 454

Structural heart disease but w/o s/sx of HF e.g. pts w/ previous MI, LV remodeling including LVH and low EF, asymptomatic valvular disease Tx: ACEI/ARB, BB as appropriate In selected pts: ICD, revascularization or valvular surgery as appropriate High risk of sudden cardiac death

Answer 455

Structural heart disease w/ sx e.g. known structural heart disease and HF s/sx Cardiology input/consult **Preserved EF Tx:** Diuresis to relieve sx of congestion, tx comorbidities **Reduced EF Tx:** Routine use: diuretics for fluid retention, ACEI/ARB, BB, aldosteronen antagonists In selected pts: Hydralazine/isosorbide dinitrate, ACEI and ARB, Digitalis, CRT, ICD, revascularization or valvular surgery

Answer 456

Refractory HF pts w/ marked HF sx at rest recurrent hospitalizations despite GDMT Tx: Advanced care measures, heart transplant, chronic inotropes, temporary of permanent MCS, experimental surgery or drugs, palliative care and hospice, ICD deactivation

Answer 457

Grade 1-3/6 Early to midsystolic heard best at LSB but usually audible over precordium No radiation beyong precordium Softens or disappears w/ standing Increases in intensity w/ activity, fever, anemia, S1 and S2 intact, normal PMI Heard in 80% of thin, healthy adults if examined in soundproof room Asymptomatic w/ no report of chest pain, HF sx, palpitations, syncope, activity intolerance

Answer 458

Gr 1-4/6 Harsh systolic murmur Usually crescendo-decrescendo heard best at 2nd RICS apex Softens w/ standing Radiates to carotids May have diminished S2 slow-filling carotid pulse Narrow pulse pressure Loud S4 Heaving PMI Greater the degree of stenosis, later the peak of murmur Dx: transthoracic echocardiogram, order when systolic murmur In younger adults - usually congenital bicuspid valve In older adults - usually calcific, rheumatic Dizziness, syncope ominous signs, pointing to severely decreased CO

Answer 459

Mitral Regurgitation Physiologic Aortic Stenosis Systolic Mitral Valve Prolapse

Answer 460

Mitral Stenosis Aortic Regurgitation Diastolic

Answer 461

Gr 2-3/6 systolic ejection murmur heard best at 2nd RICS Full carotid upstroke, not delayed No S4 No sx Benign thickening and/or calcification of aortic valve leaflets, no change in valve pressure gradient AKA: **"50 over 50" murmur** Found in 50% of those older than 50

Answer 462

Gr 1-3/4 high-pitched blowing diastolic murmur Heard best at 3rd LICS May be enhanced by forced expiration, leaning forward Usually w/ S3 wide pulse pressure sustained thrusting apical impulse more common in men usually from rheumatic heart disease but occassional d/t tertiary syphilis

Answer 463

Gr 1-3/4 diastolic murmur low-pitched late diastolic heard best at apex and localized Short crescendo decrescendo rumble, like bowling ball rolling down alley or distant thunder Often w/ opening snap, accentuated S1 in mitral area Enhanced by left lateral decubitus, squat, cough, immediately post-Valsalva Nearly all rheumatic in origin Protracted latency period, then gradual decrease in exercise tolerance leading to rapid downhill course d/t low cardiac output AF common

Answer 464

Maintenance of optimal oral health and hygiene more important than prophylactic abx to reduce risk of IE Conditions where prophylactic abx w/ dental procedures is reasonable: Prosthetic cardiac valve of prosthetic material use for cardiac valve repair Previous IE Congenital heart disease Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired CHD w/ prosthetic material or device during the first 6 months of procedure Repaired CHD w/ residual defects at site or adjacent to site of prosthetic patch/device Cardiac transplantation in recipients who develop cardiac valvulopathy

Answer 465

Give 30-60 minutes before procedure **Adults** Amox 2 g PO Ampicillin 2 g IM or IV Cefazolin or ceftriaxone 1 g IM or IV Clindamycin 600 mg Cephalexin 2 g Azithromycin or clarithromycin 500 mg **Children** Amox 50 mg/kg PO Ampicillin 50 mg/kg PO Cefazolin or ceftriaxone 50 mg/kg IM or IV Clindamycin 20 mg/kg Cephalexin 50 mg/kg Azithro/clarithro 15 mg/kg

Answer 466

Gr 1-3/6 systolic ejection murmur at pulmonic area Widely split S2, right ventricular heave Typically w/o sx until middle age, then present w/ HF Persistent ostium secundum in mid-septum Will resolve w/ ASD correction

Answer 467

Narrow splitting S2, murmur of tricuspid regurgitation SOB nearly universal Seen with RVH, RAH, as identified by ECG, echo Secondary PH may be a consequence of Redux (fen-phen) use

Answer 468

Gr 1-4/6 high-pitched blowing systolic murmur, often extending beyond S2 Sounds like long "haaaa", "hoooo." Heard best RLSB Radiates to axilla Often laterally displaced PMI Decreased w/ standing, valsalva increased by squat, hand grip Found in ischemic heart disease, endocarditis, RHD W/ RHD, often w/ other valve abnormalities (AS, MS, AR)

Answer 469

Gr 1-3/6 late systolic crescendo murmur w/ honking quality heard best at apex Murmur follows midsystolic click Click moves forward to earlier systole w/ valsalve or standing, resulting in longer sounding murmur W/ hand grasp or squat, click moves back further into systole, resulting in shorter murmur Often seen w/ minor thoraci deformities such as pectus excavatum, straight back, and shallow AP diameter Chest pain sometimes present

Answer 470

3.8-4.2 in reproductive age

Answer 471

pH White curd-like discharge usually no odor Micro: mycelia, budding yeast, pseudohyphae w/ KOH prep Itching/burning, discharge **Tx** Fluconazole 150 mg orally x 1 If complicated: Fluconazole 150 mg orally every 72 hours x 3 doses If recurrent: 150 mg once daily for 10-14 days

Answer 472

pH \> 4.5 Thin, homogenous, white, gray, adherent often increased discharge Fishy amine odor (+KOH whiff test) \> 20 clue cells/HPF Few or no WBCs Foul odor, itching occassionally present Tx: - need strong anaerobe coverage Metronidazole 500 mg BID x 7 days No ETOH during tx Metrogel (topical metronidazole) Clindamycin vaginal cream or ovules (Cleocin) Oral tinidazole (Tindamax)

Answer 473

57 inches 8-12 years

Answer 474

P4502CP inhibitor

Answer 475

altered protein binding sites

Answer 476

impairment of motor activities despite intact motor function

Answer 477

despite successful initial tx, local reccurrence is common

Answer 478

cannnot recommend in OA per evidence

Answer 479

risk of osteoporosis is reduced selective estrogen receptor modulator

Answer 480

Fluoxetine Prozac

Answer 481

Hypothyroidism

Answer 482

Effexor SNRIs increase the levels of norepinephrine and dopamine in the brain

Answer 483

clean genital/urinary area w/ cleansing wipe void some urine before beginning collection collect from middle of stream

Answer 484

Alosetron In IBS - blockage of 5-HT3 receptors (ligand-gated ion channels) may reduce pain, abdominal discomfort, urgency, and diarrhea

Answer 485

high, loud, hollow-sounding

Answer 486

evaluation for acute appendicitis Rotating right hip through full ROM, positive if pain w/ movement/flexion of hip

Answer 487

**drowsiness, blurred vision, tremors, tiredness** usually not cause for concern Stomach upset and vomiting not typically associated w/ gabapentin

Answer 488

every 1-2 weeks until symptom free, then every 3-6 months

Answer 489

Tufts of hair on a child overlying spinal column may be sign of spina bifida occulta

Answer 490

Amenorrhea Fatigue, nausea, breast changes, urinary frequency, slight increase in body temp Probable signs of pregnancy: goodell's sign, hegar's sign

Answer 491

1 cm per week after 4 weeks of gestation 6-8 weeks: pear 8-10 weeks: orange 10-12 weeks: grapefruit

Answer 492

Softening of cervix d/t increased vascularization

Answer 493

Nonsensitive sign of pregnancy softening and compressibility of lower segment of uterus via bimanual exam in early pregnancy

Answer 494

Bluish discoloration of cervix early sign of pregnancy 6-8 weeks after conception

Answer 495

Gallstones

Answer 496

Vitamin supplements and iron Avoid dairy Eat nutritious diet - low-residue, low-fat, high-protein, high-calories foods Avoid smoking, caffeine, pepper, ETOH

Answer 497

Acute glomerulephritis Also - UA will show renal casts and RBCs

Answer 498

a surrofate marker for bacteriuria Indicates bacterial reduction of dietary nitrates to nitrites by select gram-negative uropathogens including E. coli and Proteus spp.

Answer 499

decreased libido and weight gain TCAs have more weight gain Jitteriness and restlessness are commonly associated w/ SSRI use

Answer 500

All s/s of TIA including numbness, weakness, and flaccidity, visual changes, ataxia, or dysarthria resolve usually within minutes but certainly by 24 hours after onset consider stroke if \> 24 hours

Answer 501

Once BP is stabilized f/u should be every 3-6 months Normotensive pts: every 1-2 years

Answer 502

Prostaglandin analogue Specifically designed for gastric protection with NSAID use

Answer 503

Damage to corneal epithelium d/t herpes virus (shingles) Acute onset eye pain, photophobia, blurred vision in affected eye w/ rash

Answer 504

Raised and yellow soft plaques located under the eyebrow they can be on the upper or lower lids of the eyes and are located on the nasal side

Answer 505

take antacid AFTER hysocyamine and after a meal

Answer 506

constipation risk fx: \> 80 years, impaired mobility, neurologic disorders including dementia

Answer 507

HCTZ is contraindicated HCTZ has a sulfonamide ring in its chemical structure

Answer 508

Positron emission tomography Shows brain function and highlights abnormal tissue Often done after abnormal CT Evaluates for brain tumor

Answer 509

Women w/ dx of TSS should not use tampons or diaphragms in the future **s/sx of TSS:** high fever, myalgia, N&V, diarrhea, diffuse sunburn-like rash, hypotension, agitation, and confusion

Answer 510

Based on HAG Height Age Gender

Answer 511

Low metastatic risk Early recognitition and intervention is recommended Untreated BCC can lead to significant deformities and altered function

Answer 512

No fever Dyuria, decreased urinary flow, post-void dribbling, hesitancy may be associated w/ back pain or pain in testicles

Answer 513

Bananas Rice Applesauce Toast Yogurt

Answer 514

Safe during lactation contraindicated in pregnancy risk exists in theory

Answer 515

M \> 40 in F \> 35 in

Answer 516

startle reflex Disappears at 4-6 months

Answer 517

Low-frequency Heard late in diastole rare in infants and children always pathological Seen in condition w/ decreased ventricular compliance

Answer 518

Mupirocin 2% BID x 10 days and cover with DSD Gentamicin - apply BID to TID Isoretinoin 0.5-1mg/kg/day PO in divided doses Anhydrous ethyl elcohol w/ 6.35 aluminum chloride, apply TID before abx ointment

Answer 519

Aka vascular purpura common and benign condition in the elderly normal labs

Answer 520

Normal Borderline 200-239 High \> 240

Answer 521

ALL accounts for about 80% of childhood leukemia Noted for presence of lymphoblasts which replace normal cells in bone marrow T lymphocyte type of ALL has poorest prognosis B cell = Better prognosis

Answer 522

organism-specific stool antigen testing H. pylori transmitted via oral-fecal and oral-oral route spiral shaped organism

Answer 523

Low: 80-240 mcg Medium: \>240-480 mcg High: \> 480 mcg

Answer 524

Test = Dx CT angiography = coarctation of the aorta 24-hour urine mentenephrine and normetanephrine = Pheochromocytoma Doppler flow study, magnetic resonance angiography = Renovascular HTN Estimated GFR = CKD

Answer 525

8 weeks -- Uterus, nonpregnant, size of lemon and is mobile, firm, and notender 8 weeks = size of tennis ball or orange 12 weeks = size of softball or grapefruit 20 weeks = fundus at umbilicus

Answer 526

Usually detected at 3-6 years of age Best heard at middle left sternal border or between the left lower sternal border and apex when patient is supine

Answer 527

Arms, hands = 5-10 days Over a joint = 7-14 days

Answer 528

Etiology: Estrogen deficiency pH \> 5 Scant, white-clear discharge Absent KOH amine odor Few or absent lactobacilli Lactobacilli decreases w/ estrogen decrease common complaints: itching/burning, discahrge, but often w/o sx Tx: Topical and/or vaginal estrogen if symptomatic and/or recurrent UTI Oral estrogen as solo intervention likely inadequate

Answer 529

\> 50 Male Overweight Cigarette smoking

Answer 530

vaginal epithelial cells w/ adherent bacteria

Answer 531

L4 to L5 and L5 to S1

Answer 532

HHV2, less commonly HH1 Common to be asymptomatic or have atypical sx Asymptomatic transmission common Classic presentation: painful, ulcerated lesions marked lymphadenopathy w/ initial lesions In women: thin vaginal discharge if lesions at vagina or introitus **Tx:** **Acyclovir** initial episode: 200 mg 5x/day x 10 days or 400 mg 2x/day x 7-10 days Recurrence: 200 mg 5x/day x 5 days - being at earliest signs of disease - or 400 mg TID x 5 days or 800 mg BID x 5 days or 800 mg TID x 2 days Famciclovir **Valtrex** Initial episode: 1 g BID x 10 days Recurrence: 500 mg BID x 3 days Reduction of transmission: 500 mg daily

Answer 533

Chlamydia, ureaplasma, mycoplasma genitalium Friable cervix Irritative voiding sx Mucopurulent discahrge Often w/o sx Micro: large number of WBCs in discharge Tx Azithromycin 1 g x 1 dose Alternative: Doxy Erythro Ofloxacin Levofloxacin

Answer 534

Gram neg w/ propensity to produce beta-lactamase Irritative voiding sx Occassional purulent discharge often w/o sx Micro: large number of WBCs in discharge Tx Ceftriaxone 250 mg IM x 1 dose + Azithromycin x 1 dose or Doxy x 7 days Severe beta-lactam allergy: Azithro 2 g x 1 dose

Answer 535

Parasite Men almost never have itch Women seldom have itch classic sx: dysuria, itching, vulvovaginal irritation, dyspareunia, yellow-green vaginal discharge, occassionally frothy (30%), cervical petechial hemorrhages ("strawberry spots") Often w/o sx Micro: motile organisms and large number of WBCs Alkaline pH Tx: Oral metronidazole or tinidazole as 1 x dose Avoid consuming ETOH for 24 hours after metronidazole or 72 hours after tinidazole Dose: Flagyl 2 g x 1 dose

Answer 536

Treponema pallidum

Answer 537

Chancre, firm, round, PAINLESS genital and/or anal ulcers w/ clean base and indurated margins localized lymphadenopathy 3 weeks duration resolve w/o tx

Answer 538

Nonpruritic skin rash, often involving palms and soles as well as mucous membrane lesions Fever, lymphadenopathy, sore throat, patchy hair loss, headaches, weight loss, muscle aches, fatigue Resolution w/o tx possible

Answer 539

Variable presentation Gumma - rare Occurs when primary and secondary sx have resolved

Answer 540

**Benzathine penicillin G 2.4 million units IM as 1 x dose** (x 3 weeks if Latent syphilis) **Alternative tx if allergic to PCN:** Doxy 100 mg BID x 2 weeks Tetracycline 500 mg QID x 2 weeks (x 4 weeks if latent) Ceftriaxone 1 g IM or IV every 24 hours x 8-10 days

Answer 541

Condyloma acuminata HPV commonly HPV-6, -11 causing genital warts Infection w/ multiple HPV types common verruca-form lesions can be subclinical **Tx** Podofilox, liquid nitro, croprobe, trichloroacetic acid, podophyllin resin, surgical removal or imiquimod (Aldara) Imiquimod for external warts only **Imiquimod 5% cream apply at bedtime 3x/week for up to 16 weeks. Wash are w/ soap and water 6-10 hours after application** If pregnant: Trichloroacetic acid and cryoprobe

Answer 542

HPV types 1, 2, 4

Answer 543

HPV types 16, 18, 31, 33

Answer 544

Infection of upper female reproductive tract, including uterus, fallopian tubes, adjacent pelvic structures Causative organisms: N. gonorrhoeae, C. trachomatis, bacteroides, Enterobacteriaceae, streptococci

Answer 545

Irritative voiding sx fever, abd pain, CMT, vaginal discharge possible sequelae include tubal scarring w/ subsequent increased risk for ectopic pregnancy and/or infertility

Answer 546

Ceftriaxone 250 mg IM x 1 dose + Doxycycline 100 mg BID x 14 days w/ or w/o Metronidazole 500 mg BID x 14 days Metronidazole for anaerobes - studies show better outcomes when Metronidazole is added

Answer 547

Inflammation of the glans common in candida to also have scrotal involvement vs jock itch (tinea cruris) typically no scrotal involvement

Answer 548

E. coli (gram neg, most common) S. saprophyticus (gram pos.) Enterococci (gram-pos)

Answer 549

**1.) Bactrim DS BID x 3 days** if resistance \> 20% or sulfa allergy **2.) Macrobid 100 mg BID x 5 days or Fosfomycin 3g x 1 dose** + **Pyridium** OTC 2 tabs total 190 mg TID w/ or after meals x 2 days Rx 200 mg TID x 2 days w/ abx **Alternative** Ciprofloxacin 250 mg BID x 3 days Ciprofloxacin ER 500 mg daily x 3 days Levofloxacin 250 mg daily x 3 days Moxifloxacin 400 mg daily x 3 days + Pyridium (turns urine orange!)

Answer 550

Usual pathogens: E. coli, enterococci Obtain urine and blood cultures prior to initiating abx Moderately ill: suitable outpatient Usually F, 18-40 y, fever 102 or higher, CVA tenderness **Tx** **Ciprofloxacin 500 mg BID x 7 days** **Ciprofloxacin ER 1000 mg daily x 7 days** **Ofloxacin 400 mg BID x 7 days** **Levofloxacin 250 mg daily x 5 days** **One IV dose often given d/t GI upset** **Alternative:** Amox-Clav x 14 d Cephalosporin x 14 d TMP/SMX DS x 14 d

Answer 551

Usual pathogen: Gono/chlamy Irritative voiding sx Fever, painful swelling of epididymis and scrotum (typically asymmetrical) Infertility potential post-infection Prehn sign = relief w/ discomfort w/ scrotal elevation + **Tx:** Ceftriaxone 250 mg IM x 1 dose + Doxy 100 mg BID x 10 days Advise scrotal elevation to help w/ sx

Answer 552

Causative organism: Enterobacteriaceae (coliforms) (Gram negative) Irritative voiding sx Fever, painful swelling of epididymis and scrotum Intertility potential post infection **Primary tx:** Ciprofloxacin 500 mg daily x 10-14 days Levofloxacin 750 mg daily x 10-14 days **Alternative** IV ampicillin w/ sulbactam (the IV augmentin) 3rd gen cephalosporin other parenteral agents as indicated by severity of illness

Answer 553

Gono/chlamy Irritative voiding sx, suprapubic pain, perineal pain, fever tender, boggy prostate leukocytosis "sitting on a rock" **Tx** Ceftriaxone 250 mg x 1 dose + Doxy 100mg BID x 10 days

Answer 554

Enterobacteriaceae (coliforms) Irritative voiding sx, suprapubic/perineal pain, fever tender, boggy prostate leukocytosis **Tx:** Ciprofloxacin 500 mg BID x 14 days or Ofloxacin 200 mg daily x 14 days

Answer 555

firm, smooth size of walnut about as firm as tip of nose

Answer 556

Tender, boggy, indurated About as firm as cheekbone

Answer 557

nodular, firm Usually malignant lesions are not palpable until disease is advanced Order testicular U/S then refer to urology

Answer 558

Textile worker (dyes) Smoking Intermittent painless gross hematuria (90%) 10% microscopic hematuria

Answer 559

Delirium Infection (urinary) Atrophic urethritis and vaginitis Pharm (diuretics) Psychological disorders (depression) Excessive urine output (HF, DM) Restricted mobility Stool impaction

Answer 560

**Most common in elders** Strong senstation to empty the bladder that cannot be suppressed Coupled w/ involuntary loss of urine **Tx:** **Anticholinergics (antimuscarinics)** Detrol (tolterodine) Ditropan (oxybutynin) Vesicare (solifenacin succinate) Enablex (darifenacin) Toviaz (fesoterodine fumarate) **Alternative:** B3 agonist (receptors found in gallbladder, urinary bladder, brown adipose tissue) Mirabegron (Myrbetriq) Botulinum toxin injections

Answer 561

Most common form in women Rare in men, occassionally noted post prostate/bladder sx Loss of urine w/ incrase in intaabdominal pressure such as coughing, sneezing, exercise Tx: Support to area w/ vaginal tampon, urethral stents, periurethral bulking agent injections, and pessary use Kegel most helpful in younger pts Pelvic floor rehab w/ biofeedback, electerical stim, bladder training Surgery = for well-chosen candidates

Answer 562

Assoc. w/ inability to get to toilet or lack of awareness of need to void pts w/ mobility issues/altered cognition worsened by unavailability of a helper to assist in toileting activities Tx: Ameliorated by having assistant aware of voiding cues to help w/ voiding activities

Answer 563

Assoc. w/ acute event such as delirium, UTI, medication use, restricted activity Tx of underlying process (e.g. d/c med)

Answer 564

Colposcopy

Answer 565

Retracted foreskin that cannot be brought forward to cover the glans Emergency!

Answer 566

Palpable "nest of worms" scrotal mass Only evident in standing position

Answer 567

Collection of serous fluid causes **_painless_** scrotal swelling easily recognized by transillumination

Answer 568

Foreskin cannot be pulled _back_ to expose the glans

Answer 569

Testicular torsion Emergency!

Answer 570

Testicle located in inguinal canal or abdomen Standard: wait until 1 year of age for intervention

Answer 571

Recommended for all HIV infected individuals to reduce risk fo disease progression Start ART CD4 ART at CD4 \> 500 (moderate recommendation) All pregnant women regardless of CD4 (strong recommendation)

Answer 572

_Strong recommendation_ for ART to be used in individuals to prevent transmission (e.g. perinatal transmission, heterosexual transmission, transmission risk groups such as sex workers etc.) PMCT - prevention of mother to child transmission PrEP - pre-exposure prophylaxis (HIV-negative pts at high risk for exposure) - ART reduces transmission by up to 92% PEP - post exposure prophylaxis

Answer 573

M. pneumo C. pneumo B. pertussis _Not Strep pneumo!_

Answer 574

few days to a week after starting

Answer 575

RSV is implicated in causing AOM

Answer 576

HIV 2 for initiation and 2 for continuation AIDS 3 for initiation and 2 continuation

Answer 577

Systemic corticosteroids

Answer 578

Anaphylaxis Infection MI **NOT DM1**

Answer 579

Alteration in shape of RBCs

Answer 580

pancreatitis

Answer 581

Large forehead elongated face large or protruding ears flat feet larger testes low muscle tone intellectual disability most common cause of autism in either gender Girls 50% have normal cognitive function Girls w/ milder features

Answer 582

Recommended 15-65 y Men who have sex w/ men Active injection drug users Behavioral risk fx (unprotected sex, infected sexual partners, bisexual orientation, sex worker) **Dx:** Repeated reactive immunoassay followed by confirmatory western blot or immunofluorescent assay

Answer 583

Remission of sx for 4-5 months or more Aimed at virtual elimination of a person's sx of depression/anxiety restoration of psychosocial and occupational function Consider long-term tx if 2nd or later episode

Answer 584

urgent need for response pts who are suicidal or refusing food and nutritionally compromised psychotic sx or catatonia

Answer 585

From most to least energizing: Fluoxetine (Prozac) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) **Serotonin = smooths mood**

Answer 586

**S**_S_**NRI** Venlafaxine (Effexor) Duloxetine (Cymbalta) desvenlafaxine (Pristiq) **Norepinephrine = Focus** Occassional reports of being energizing, helpful in anxious and/or resistant depression **SNRI** - Strattera (ADHD)

Answer 587

Selective Dopamine Reuptake Inhibitor Bupropion (Wellbutrin) Potentially activating, usually used as add-on tx w/ SSRI

Answer 588

use of antidepressants increased risk of suicidality in children, adolescents and young adults 24 y/o and younger Short term studies have shown no increase in pts \> 24 y/o reduction in risk in pts \> 65 compared to placebo

Answer 589

Benzodiazepines buspirone (Buspar) - effective when given w/ high enough dose and long-enough (at least 6 weeks) Potentially helpful in alleviating hypervigilance associated w/ anxiety but use does not decrease worry

Answer 590

SSRI and SNRI = 40% SDRI = 20% Anorgasmia, ED, impaired libido

Answer 591

Paroxetine (Paxil) Increase in constipation, dry mouth, confusion in gero

Answer 592

Fluoxetine (Prozac) Half life 82 hours, metabolite = 7-15 days CYP450 Isoenzyme inhibition One of the oldest in the market

Answer 593

Citalopram (Celexa) QT prolongation risk increased w/ increased dose

Answer 594

Escitaloporam (Lexapro) Citalopram (Celexa) Sertraline (Zoloft) - Paroxetine (Paxil) Fluoxetine (Prozac)

Answer 595

TCAs = cardiac and neurotoxic May cause cardiac dysrhythmias and seizures

Answer 596

Lag of a number of weeks in onset of SSRI therapeutic effect is expected Frontal headache is a common short-term problem w/ early SSRI use

Answer 597

Erikson Infant 0-1 year Task: reliable caregiver Pathologic outcomes: depression, substance abuse, psychosis

Answer 598

Erikson Toddler 1-3 years Task: need to learn to explore world. Parent should not be too smothering or too neglectful Pathologic outcome: paranoia, obsessions, compulsions, impulsivity

Answer 599

Erikson Preschool 3-6 years Task: ability to do things on his/her own Pathologic outcomes: Conversion disorder, phobia, psychosomatic disorder

Answer 600

Erikson School age 6-11 years Task: self-worth, compared to others Pathologic outcomes: creative inhibition, inertia

Answer 601

Adolescent 12-20 years Task: who am I Pathologic outcome: delinquent behavior, gender identity issues, borderline personality disorder, psychotic episodes

Answer 602

Young adult hood 21-40 years Task: forming loving relationships Pathologic outcomes: schizoid personality disorder

Answer 603

40-60 years Task: accept self, establish and guide next generation Pathologic outcome: mid-life crisis

Answer 604

65 years and older Task: sense of accomplishment/integrity Pathologic outcome: extreme alienation, despair

Answer 605

_sudden state_ of rapid changes in brain function confusion, changes in cognition, activity, LOC Precipitated by acute underlying cause Abrupt onset over hours to days Impaired but variable recall Usually reversible to baseline **Often worse as the day progresses (sundowning)** Usually change in psychomotor activity Perceptual disurbances including hallucinations Speech content incoherent, confused, w/ wide variety of inappropriately used words

Answer 606

Slowly developing impairemnt of intellectual or cognitive function progressive and impairs w/ normal functioning Variety of causes Insidious onset Cannot be related to precise date Gradual change in mental status reports of good and bad days Memory loss esp. w/ recent events Duration of months to years Chronically progressive and irreversible Disturbed sleep-wake cycle lacks hour-to-hour variability Often day-night reversal no psychomotor involvement until later in disease No perceptual disturbance until later in disease Earlier stages - word searching, progressing to sparse speech content Mute in later disease

Answer 607

D - drugs E - Emotional (mood disorders) L - Low PO2 (hypocemia from CAP, COPD etc) I - Infection (UTI most common, then CAP) R - Retention of urine/feces R = Reduced sensory input (blindness, deafness) I - Ictal or postictal state (ETOH withdrawal) U - Undernutrition M - Metabolic (poorly controlled DM, hypo/hyperthyroid M - Myocardial patients S - Subdural hematoma (can be result of minor head trauma d/t brain atrophy and fragile blood vessels)

Answer 608

Treat underlying cause Infection, medication, and fractures are most common

Answer 609

Alzheimer 50-80% Vascular (multi-infarct) 20% Parkinson's 5% Miscellaneous: HIV, dialysis encephalopathy, neurosyphilis, NPH, Pick's disease, Lewy body, frontotemporal dementia, others \*30% of Alzheimers also have vascular dementia - consider if quick deterioration

Answer 610

Bun, Cr Glucose Calcium, Sodium Hepatic enzymes B12, Folate TSH RPR/VDRL CBC w/ diff UA, C&S - highest yield ECG As directed by patient risk fx and presentation: CT, MRI (fall, etc) PET scan (tumor) Toxic screen CXR - resp ESR - inflamm HIV other

Answer 611

**Vitamin E 1000 IU BID** **OR** **Selegiline 5 mg BID** No benefit to using BOTH at the same time

Answer 612

Tobacco use

Answer 613

**Cholinesterase inhibitors** donepezil (Aricept) rivastigmine (Exelon) galantamine (Razadyne) Clear though minor time-limited benefits by increasing availability of acetylcholine Allows pts to stay longer in their home

Answer 614

N-methyl-D-aspartate receptor antagonist memantine **Namenda** Through effect on glutamate, helps create an environment that allows for storage and retriebal of information Used in earlier disease w/ cholinesterase inhibitor -- \*Aricept (donepezil) also approved for use in advanced AD

Answer 615

40% of pts w/ dementia also have depression standard antidepressant tx is indicated keep in mind drug-drug

Answer 616

If environmental manipulation fails to eliminate agitation or psychosis, consider tx w/ antipsychotic **Second-generation antipsychotic** best studied for this indication (aka atypical antipsych) Increased risk for stroke and cardiovascular events in older adults w/ dementia **Worsens insulin resistance = increased clot risk**

Answer 617

Increase fall and fracture risk

Answer 618

Potential lack of efficacy in impaired renal function of Cr Cl

Answer 619

TCA Significant risk of orthostatic hypotension

Answer 620

(NSAID) Potential to promote fluid retention

Answer 621

Increased risk for hyponatremia Check electrolytes in 1 month after starting

Answer 622

Transient loss of consciousness Vasovagal, cardiac outflow obstruction (hypertrophic cardiomyopathy, valvular, especially high-grade aortic stenosis, aortic dissection, dysrhythmia) Orthostatic hypotension

Answer 623

In the first year of life is 12 cm 6 cm in the first 3 months 3 cm in the 4th to 6th months and 3 cm in the 6th to 12th months Subsequent head growth is about 0.5 cm/year for 2-7 year olds

Answer 624

No resources for self-care at home Age 60 and older PO2 of RR \> 30 breaths

Answer 625

Pediatric pts Pregnant women Lactating women

Answer 626

awake state or momentary loss of consciousness w/ abnormal motor behavior lasting seconds to minutes

Answer 627

a group of physical signs that may indicate non-organic or psychological component to chronic low back pain

Answer 628

inverted T wave and T wave depression

Answer 629

ST elevation w/ tall peaked T wave

Answer 630

pathologic Q wave

Answer 631

Carbamazepine induces estrogen metabolism = OCP failure

Answer 632

less than helpful way to reduce drug levels in mother's milk creates area of lower drug concentration in empty breast which enables drug to diffuse from area of high concentration to area of low concentration (breast milk)

Answer 633

HIGH-pitched, pansystolic murmur heard best at apex radiates to axilla Loid-blowing Use diaphragm of stethoscope

Answer 634

with treatment 2-5 days without treatment 5-7 days

Answer 635

through physiologic healing takes 12-24 months

Answer 636

Cardiac output increases by 1/3 the last two trimesters Heart is displaced upward to the left in the late second to third trimester Thyroid can enlarge by as much as 15%

Answer 637

Levodopa = decreased effect of both iron and levodopa, separate medications by as much time as possible, increase Levodopa dose if needed Tetracyclines: decreased tetracycline and iron effect Antacids: decreased iron absorption Caffeine: decreased iron absorption

Answer 638

Prozac 20-80 mg daily Zoloft 50-200 mg daily Celexa 40-60 mg daily Lexapro: 10-20 mg daily

Answer 639

ACEIs decrease mortality and prolong survival in clients w/ CHF Prescribe for all pts with systolic dysfunction unless contraindicated

Answer 640

NSAIDs Oral contraceptives Generally, use one agent then add the other if one does not work alone

Answer 641

Early Localized disease fever, chills, myalgia, headache erythema migrans 1 week after tick bite (7-10 days) Common in areas of tight clothing (groin, thigh, axilla)

Answer 642

Early disseminated infection weeks to months later Bacteremia (50-60% of pts w/ erythema migrans) Secondary skin lesions within days to weeks of original infection in 50% of pts malaise, fatigue, fever, h/a, neck pain, generealized achiness common w/ skin lesions Myopericarditis w/ atrial of ventricular arrhythmias 4-10% Neurologic 10-15% Aseptic meningitis w/ mild h/a and neck stiffness sensory or motor radiculopathy and mononeuritis multiplex occur less frequency Panophthalmitis (rare)

Answer 643

Late persistent infection Months to years later Musculoskeletal manifestations in 60% Monoarticular or oligoarticular arthritis of knee or other weight-bearing joints Chronic arthritis develops in about 10% of pts Neurologic manifestations (rare) Subactue encephalopathy Intermittent paresthesias often in stocking glove distribution radicular pain Severe encephalomyelitis Cutaneous manifestation Usually bluish-red discoloration of distal extremity w/ associated swelling Lesions atrophic and sclerotic

Answer 644

Leg pain/numbness during activities (intermittent claudication) Persistent infections or sores on leg/feet Pale/bluish color to skin May be asymptomatic Etiology: plaque in arteries limiting blood flow **Main risk fx: SMOKING** Other risk fx: HTN, age, HL, elevated BG **Dx: ABI , doppler U/S or MRI to assess bloodflow** Treadmill test to evaluate severity of sx Arteriogram to identify blocked arteries **Tx:** Smoking cessation, physical activity, weight loss, contol BP, HL, BG Antiplatelets (ASA) to prevent blood clots **Cilostazol and Pentoxifylline** to reduce PAD sx, surgery to improve blood flow

Answer 645

Common sx: burning, swelling, throbbing, cramping, aching, and heaviness in the legs, restless legs and leg fatigue, telengiectasias (spider veins) Etiology: congenital absence of/or damage to venous valves resulting in reflux through superficial veins, thrombus formation can also cause valve failure Exam: Duplex U/S can be used to assess blood flow in veins and eliminate other causes **Tx:** Physical activity, weight loss Use of compression stockings to decrease swelling Various techniques to remove the refluxing superficial vessels (e.g. sclerotherapy or ablation)

Answer 646

Gradual onset of numbness and tingling in hands/feet Burning pain, sharp/electric-like pain, muscles weakness, extreme sensitivity to touch Etiology: damage to nerves extending to peripheral system, DM most common cause. Others: traumatic injuries, infections, toxins Dx: EMG or nerve biopsy **Tx:** NSAIDs mild pain antiseizures and antidepressants Lidocaine patch Opioids (when other tx fail) TENS can help relieve sx

Answer 647

CN III or IV

Answer 648

CN III or VI

Answer 649

Dilation of the pupils

Answer 650

Constriction of the pupils

Answer 651

3-5 years after menopause

Answer 652

Clay or putty colored Occur briefly in viral hepatitis but are more common w/ obstructive jaundice

Answer 653

10 days to 3 months after pathogen exposure primary sx appear

Answer 654

anal abscess esp. w/ fever and chills

Answer 655

CN V Trigeminal nerve - innervates the masseter, temporalis, and the internal pterygoids

Answer 656

coracoid process

Answer 657

internal rotation of shoulders

Answer 658

Semimembranous bursitis

Answer 659

anserine bursitis

Answer 660

infrapatellar bursitis

Answer 661

prepatellar bursitis

Answer 662

prepatellar bursitis

Answer 663

3-4 days (range 1-10 days) also the period of communicability Bacteria can be found for 2-4 days in the nose and pharynx and for up to 24 hours after starting abx

Answer 664

Will resolve in 1-2 weeks w/o surgical intervention Surgical excision of overlying skin can provide rapid symptomatic relief Cool compresses, sitz baths, stool softener, analgesics can be used if surgical intervention is not available

Answer 665

Gross painless hematuria Mircroscopic hematuria in about 20% Irritative voiding sx occassionally Abnormal abd mass only w/ advanced disease

Answer 666

cause by compromised renal function and hydronephrosis 5% of all renal failure Urea nitrogen and creatinine elevation urinary retention and outflow obstruction Intervention: relieve urinary outflow obstruction Renal function returns to baseline if promptly detected

Answer 667

Bladder dysfunction, perineal sensory loss, anal laxity Neurological deficit in lower extremities Lower extremity motor weakness

Answer 668

aka tonic-clonic seizures rigid extension of arms and legs followed by sudden jerking movements w/ loss of consciousness bowel/bladder incontinence is common w/ postictal confusion

Answer 669

Annual screening w/ low-dose computed tomography Age 55-74 w/ smoking hx of at least 30 packs/year Current smokers or who have quit in the past 15 years

Answer 670

Haemophilus ducreyi

Answer 671

Decline in condition more than expected for age No change in ADLs 3-19% in those \> 65 First sx: memory loss Risk Fx: Age, low education level, h/o depression, lack of exercise, African ancestry, HTN, HL, ApoE allele Multiple etiologies Tx: Acetylcholinesterase inhibitors may delay but not prevent Good health habits Volunteer or stay cognitively active \> 50% will progess to dementia within 5 years Depression doubles risk

Answer 672

50-70% of all dementia at age 85 11% of M and 14% of F First sx: memory loss Risk fx: Age, female, AA and Hispanics \> Caucasian, Down Syndrome, being a mother of a child w/ Down, genetic vulnerability Acquired risk fx: HTN, lipoproteins, cerebrovascular disease, altered glucose metabolism and brain trauma Biological: neuritic plaques, neurofibrillary tangles, synaptic loss throughout cerebral cortex and limbic system Tx: Mild to Moderate AD: Acetylcholinesterase inhibitors Moderate to severe AD: NMDA receptor antagonists SGAs w/ caution Reminiscence therapy, personalized music, social interactions, redirection, reassurance, family support Average lifespan after dx is 6-9 years

Answer 673

Often co-occurs w/ AD = mixed dementia, likely the second most common dementia As solo cause: third most common dementia at 8-15% First sx: often, but not sudden, variable, apathy, falls, focal weakenss, disorientation, anxiety/depression Risk fx: increasing age, male, HTN, HL, smoking, DM Bio: cortical and subcortical infarcts Tx: Cholinesterase inhibitors may help Treat vascular risks Physical activities Intellectually stimulating social activity Shortens lifespan by 3 years

Answer 674

15-20% of late-onset dementia Fluctuating presentation, visual hallucinations, may present as a psych disorder, REM, sleep disorder, delirium, parkinsonism, repeated and unexplained falls Risk fx: more common in men, ApoE allele found more often in pts w/ DLB Bio: Lewy bodies are dense intracellular neuronal inclusions found in the cortical, subcortical area of the brain EEG can help distinguish DLB and AD, but not betweent VaD and AD or diffuse DLB Tx: First-generation antipsychotic use can result in neuromuscular sensitivity SGAs helpful w/ psychosis w/o adverse effects Treat depression Anticholinesterase use can benefit memory Variable course, generally more rapid than AD Time from dx to death 6 years Mean age of dx 68, death by 75

Answer 675

Group of related disorders that cause degeneration of the frontal and temporal lobes (e.g. Pick's dementia) Insidious onset and gradual progression Personality changes cause more problems than cognitive Apathy, poor judgment/insight, speech/language, hyperorality Familial risk possible Bio: Pick's disease has marked frontal and temporal atrophy **Tx** Symptomatic psych tx (SSRI for depression, psychostimulant for apathy, risperidone for problem behaviors) Protect pts from his or her indiscretions Generally slow progression

Answer 676

10% uric acid overproduction 90% urate under-excretion - made worse by renal insufficiency, ETOH, use of loop or thiazide, ASA, other medications, and purine-rich foods including organ meats, forms of seafood including sardines and achovies, spinach, oatmeal

Answer 677

Tests for meniscal tear

Answer 678

Tests for ankle instability

Answer 679

tests for carpal tunnel

Answer 680

tests for carpal tunnel

Answer 681

ACL tear The Lachman test is performed by placing the knee in 30 degrees of flexion and then stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand, thereby attempting to produce anterior translation of the tibia. An intact ACL limits anterior translation and provides a distinct endpoint. Lack of a distinct endpoint suggests ACL injury.

Answer 682

Tests for lumbar nerve root compression

Answer 683

Test for cervical nerve root compression The Spurling maneuver is used to detect cervical radiculopathy. Several positions of the head may be tested to provoke nerve irritation. First, the maneuver is performed with the head held in a neutral position. The examiner taps or presses down on the top of the head. If this fails to reproduce the patient's pain, the procedure is repeated with the head rotated to the affected side and hyperextended.

Answer 684

Rotator cuff evaluation The integrity of the supraspinatus tendon can be assessed with the active painful arc test and the "drop arm" test. The active painful arc test (not to be confused with the Neer test, an impingement test performed passively and described separately) simply involves having the patient actively abduct their arm in the scapular plane from a neutral position. Pain with active abduction beyond 90 degrees marks a positive test. The drop arm test assesses the ability of the patient to lower his or her arms from a fully abducted position. A positive test occurs when the patient is unable to lower the affected arm with the same smooth coordinated motion as the unaffected arm

Answer 685

Jobe's test (or the "empty can" test) assesses supraspinatus function. The patient places a straight arm in about 90 degrees of abduction and 30 degrees of forward flexion, and then internally rotates the shoulder completely. The clinician then attempts to adduct the arm while the patient resists. Pain _without_ weakness suggests tendinopathy; pain _with_ weakness is consistent with tendon tear.

Answer 686

DeQuervain's tenosynovitis

Answer 687

Pain and stiffness in shoulders and hips frequently coexists w/ giant cell arteritis Responds to low dose prednisone tx of 10-20 mg/day whereas GCA can cause blindness and requires high-dose prednisone tx (40-60mg/day) Affects pts \> 50 **Polymyalgia** = fever, malaise, weight loss, anemia and markedly elevated ESR, muscle pain much greater than muscle weakness **GCA** = h/a, scalp tenderness, visual sx, jaw claudication, throat pain, temporal artery may be nodular, enalrged, or pulseless Fever can be as high as 40C and accopanied w/ rigors and sweats

Answer 688

Inflammation of unknown origin affects muscles and joints \> 50 years Sx: aches in shoulder, neck, upper arms, lower back, hips, and thighs Sx tend to come quickly and are worse in the morning w/ improvement during the day No specific dx test, CRP and ESR are typically elevated MRI or U/S of shoulder an dhip can detect inflammation Tx: Low-dose corticosteroid 10-15 mg/day until sx are relieved (typically within 2-3 weeks), followed by tapering to find lowest dose necessary to suppress sx Tx can continue up to 2-3 years

Answer 689

50 y and \> **Standing discomfort w/ improvement in sx with bending forward** Pseudoclaudication (leg pain that worsens w/ activity and improves w/ rest) Bilateral LE numbness/weakness in the majority For sx persisting \> 1 month = consider MRI, EMG, nerve conduction velocity (NCV) Tx: PT NSAIDs epidural corticosteroid injection Surgery

Answer 690

aka Reiter's syndrome Can't see Can't pee Can't climb a tree Most commonly in young men Arhtitis most commonly asymmetric and frequently involves large weight bearing joints (knee and ankle) Systemic sx: fever and weight loss common at onset Urethritis, conjunctivitis, uveitis, mucocutaneous lesions Tx: NSAIDs maintstay of tx Pts who do not respond to NSAIDs, try sulfasalazine 1000 mg BID or methotrexate 7.5 to 20 mg per week Anti TNF agents may be effective in refractory cases For chronic reactive arthritis assoc. w/ chlamydial infection, combination abx taken for 6 months is more effective than placebo Most signs of disease disappear within days or weeks Arthritis may persist for several months or become chronic Refer to rheumatology for progressive sx despite therapy

Answer 691

Irritation of the patellar tendon on the tibial tuberosity during a growth spurt Patellar swelling and pain in adolescents who participate in sports involving running and jumping Repeated stress causes inflammation below patellar tendon where it attaches to tibia Sx: pain, swelling, and tenderness in one or both knees Can be mild to debilitating Can be constant or only when performing certain activities X-ray can be used to evaluate patellar tendon **Tx:** NSAIDs and PT Strengthening exercises for quads can help stabilize knee joint Sx typically resolve at completion of growth spurt

Answer 692

Thickening of synovial tissue w/ excessive fluid within the bursa resulting in knee pain and swelling Caused by joint overuse, trauma, infection, or arthritis Focal tenderness and swelling Abrupt onset ROM full but limited by pain **First line tx: bursal aspiration** Alternative tx: Minimizing offending activity ICE to area for 15 minutes 4x/day NSAIDs If no improvement in 4-8 weeks, intrabursal corticosteroid injection should be performed

Answer 693

Disruption of meniscus - C-shaped fibrocartilage pad located between the femoral condyles and tibial plateaus Often found in athletes d/t twist type knee injury Effusion w/ knee tightness and stiffness ROM limited by discomfort Larger tears often report knee locks, makes popping sound, or "gives out" Dx: MRI can be used to identify type and extent of tear McMurray test and Apley grinding test are highly specific but not sensitive Tx: Rest, elevation, ice, analgesia Aspiration can be considered if no improvement after 2-4 weeks Arthroscopy for debridement and repair should beb considered at 4-6 weeks w/ no improvement or earlier if joint locking and effusion are problematic

Answer 694

Spasm, irritation of LS spine supporting muscles Most common reason for low back pain Spasm, ache, stiffness, position, activity, rest typically impacts pain Paraspinal muscle tenderness and spasm LS curve straightening Decreased LS flexion Neurological exam WNL **Tx:** NSAID/APAP Physical conditioning/therapy Limiting potentially harmful activities Heat or ice as indicated by pain response Muscle relaxers can be helpful but all sedting, some w/ abuse potential

Answer 695

Irritation or damage of neural structures such as disks L4-L5, L5-S1 most common sites of disk bulge Sharp, burn, electric-shock sensation Worse when increased spinal fluid pressure Sneeze, cough, straining evokes sharp pain Dx: Signs of LS strain + altered neuro exam Abnromal straight leg raise Sensory loss altered DTRs Tx: NSAID, APAP Physical conditioning/therapy Specialty eval if rapidly evolving defect, persistent neurological defect w/o resolution after 4-6 weeks of coservative tx

Answer 696

BMD -2.5 SD or below If fractures, deemed severe or "established" osteoporosis

Answer 697

BMD -1.0 to -2.5

Answer 698

F 65 and \> M 70 and \> Postmenopausal, menopausal transition M 50-69 w/ risk fx Adults w/ condition (e.g. RA) or taking a medication (long-term glucocorticoid) assoc. w/ low bone mass or bone loss Risk Fx: Lifestyle (low calcium intake, ETOH abuse, sedentary) Genetic (CF, Gaucher's disease) Hypogonadal states (androgen insensitivity, hyperprolactinemia) Endocrine disorders (DM, adrenal insuff.) GI disordres (celiac, IBD) Hematologic (multiple myeloma, leukemia) Rheumatoid and autoimmune disorders (lupus, RA) CNS disorders (MS, epilepsy) Misc. other conditions and diseases (AIDS/HIV, CHF) Drugs (long-term corticosteroids, some anticonvulsants, thyroid hormones)

Answer 699

Tx Who: Tx if BMD Postmenopausal women and men 50 and \> w/ low bone mass and 10-year hip fracture probabilty of 3% or more or all major osteoprosis-related fracture of 20% or more Hx of hip or vertebral fx Tx Options: Biphosphonates (Alendronate, ibandronate, risedronate, zoledronic acid) Calcitonin (Miacalcin) Estrogens or hormone tx (Evista) Parathyroid hormone All should be given w/ Vit D and Ca Vit D 800-1000 IU/d Ca 1000 mg/d F \> 50y and M \> 80y should have Ca 1200 mg/d

Answer 700

Dairy and nondairy Spinach sardines tofu almonds

Answer 701

X-ray is used to distinguish OA from other types of arthritis Imaging will show narrowing of joint space, change in bone, and presence of bone spurs (osteophytes) Sx: pain, tenderness, stiffness (more prominent in the morning), reduced ROM and crepitus frequently present Erythema and warmth usually absent

Answer 702

37-38 weeks plus 6 days sleepy baby wake to feed every 2 hours

Answer 703

39 weeks to 40 weeks plus 6 days

Answer 704

41 weeks to 41 weeks and 6 days Wide awake baby

Answer 705

42 weeks and beyond Induction considered at 41 to 42 weeks

Answer 706

Formula: 1.5-3 oz every 2-3 hours Breastfeeding: every 1.5-3 hours, no more than 4 hours w/o feeding, minimum 8-12 feedings/day

Answer 707

Formula: 4-5 oz every 2-4 hours Breastfeeding: 7-9x/day, dictated by infant

Answer 708

Formula: 4-6 oz every 3-4 hrs Breastfeeding: 6-8x/day, dictated by infant and if supplemental feedings

Answer 709

Formula: 6-8 oz every 4-5 hours Breastfeeding: 4-6x/day, dictated by infant, supplemental feedings

Answer 710

May start 4-6 months Solids not really needed until 1 year of age

Answer 711

Baby should make at least 6 wet diapers a day Newborns often lose up to 10% of birthweight in the first week of life Should be back up to birth weight by 2 weeks Breastfed baby usually ahs 4 or more bowel movements/day Frequent soft stools are normal Best vision range 8-12" - distance from breast & mom's face Bluish scleral tint normal until few months old Newborn's eyes are quite light and glare sensitive If object moves toward newborn's eye, baby will likely react w/ defensive blink reflex (present at birth) Well-developed sense of smell Hear high-pitched voices best Will react to cry of other neonates Visual preference for human face Place baby in a face-up position for sleep

Answer 712

Can lift self up on 2 arms from tummy Responds 2 sounds Smiles when smiled 2

Answer 713

Reaches 4 a toy or other object Smiles 4 fun Rolls from tummy to back

Answer 714

Looks like number 6 when sitting up Rolls from back to tummy and back

Answer 715

Once able to sit up, child can transfer objects from hand to hand with ease

Answer 716

Stands tall like the number 1 and walks on 2 legs

Answer 717

Can name single word objects Says "no" a lot, like an 18 y/o Acts like an 18 y/o by copying work that adults do

Answer 718

Builds a 2 block tower with ease Can walk up to 2nd floor with help (stairs) Speaks in 2 word sentences Follows 2 step commands

Answer 719

Rides a TRIcycle Build a 3 block tower w/ ease Can draw a circle Speaks in 3 word sentences

Answer 720

Speaks in 4 word sentences Can build a 4 block tower w/ ease Can draw a cross

Answer 721

Speaks in 5 word sentences Can draw a square

Answer 722

Can draw a triangle Speak in 6 word sentences

Answer 723

Lower central incisors first at 6-10 months Upper central incisors 8-12 months Lateral incisors 9-13 months First Molar 13-19 months Second Molars 23-31 months

Answer 724

Onset day 3-4 of life Maternal hormonal influences are likely cause Breast engorgement will resolve w/o intervention within the first two months of life

Answer 725

In most instances, foreskin is not easily retractable until the child is about 3 years old Ok as long as urine comes out as a steady stream

Answer 726

Incomplete sealing of peritoneal cavity at inguinal area during gestation, leaving communication between abdominal cavity and scrotum Fluid-filled scrotal sac; transilluminates, nontender, testes normal **Size varies w/ position** (larger in dependent upright position, and smaller after laying flat such as awakening) Due to communication, infant at **risk for herniation** of abdominal contents **Referral to pediatric urologist or surgeon**

Answer 727

Risk fx: femoral hernia, advanced age, recurrent hernia s/sx: Painful to palpation Fever Erythema of groin skin s/sx of bowel obstruction (N&V, abd pain and bloating) Systemic sx if strangulation and bowel necrosis has occurred Peritonitis typically does not occur because ischemic/necrotic tissues is trapped within hernia sac, however, if spontaneously or unwittingly reduced, peritoneal signs may be present

Answer 728

Sealing of abdominal cavity during gestation w/ residual trapped peritoneal fluid in scrotal sac **s/sx** fluid-filled scrotal sac, transilluminates, no change in scrotal size w/ position change, same at bedtime and on awakening **Tx** Reassurance, no risk of herniation, no special skin care needed Usually resolves by age 2 years w/o intervention Referral only if size interferes w/ activity/comfort

Answer 729

Mouth covers areola Lips are flanged out no dimpling of the baby's cheeks No clicking sound w/ sucking

Answer 730

usually seen first in the face then progress caudally to trunk and extremities encourage at least 8-12 feedings at the breast per day while avoiding dextrose and water feedings - this will help minimize newborn's risk of hyperbilirubinemia Onset of jaundice within the first 24 hours of life is pathologic until proven otherwise

Answer 731

thickening of the pylorus muscle preventing food from moving from the stomach to small intestines Nonbilious vomiting (often projectile) or regurgitation Dehydration and malnutrition Jaundice Approx. 4:1 M:F ratio Baby eager to eat again immediately post emesis Condition usually present 3 weeks of life **Dx: U/S to detect thickened pyloric muscle** An enlarged pylorus ("olive") can often be palpated in the RUQ of abdomen Tx: **surgery** stadard of care

Answer 732

Caused when a section of intestines invaginates into adjoining intestinal lumen, causing bowel obstruction If left untreated, is uniformly fatal in 2-5 days S/Sx Vomiting, abdominal pain, passage of blood and mucus Lethargy Palpable sausage-shaped abdominal mass Sx often preceded by URI Usually in the first year of life Currant jelly loose stools Sudden onset colicky, severe, and intermitted abd pain Dx: U/S to identify target and pseudokidney signs **Contast enema is the traditional and most reliable dx approach** Plain x-ray only identifies about 60% of cases Tx: Non-operative include hydrastatic or pneumatic enemas, surgical reduction needed if unsuccessful or if obvious perforation is present

Answer 733

Short-term isolation to decrease undesirable behavior Child sits in special place, easily observed by parent/caregiver, uninteresting, and only used for time out. Avoid use of bed, bedroom, or any place where child could be frightened **Start at 18-24 months** **1 minute/year of life** **Set timer**

Answer 734

nearly 100%

Answer 735

4.5 year old Simple abstract problem solving

Answer 736

Pneumococcal conjucate 13-valent (PCV13)

Answer 737

18 months and 24 months | (formal screening)

Answer 738

Give hep B immunization and hep B immuneglobulin to newborn

Answer 739

No big smiles or other warm/joyful expression by 6 months No back-and-forth sharing of sounds/smiles/other facial expressions by 9 months Lack of response to name, no babbling or baby talk and/or no back and forth gestures such as pointing, waving, reaching by 12 months No spoken words by 16 months No meaningful two-word phrases that don't involve imitating or repeating by 24 months

Answer 740

First days of life

Answer 741

Flat facial profile Poor Moro reflex Hypotonia Hyperflexible joints Excessive skin on neck Slanted palpebral fissures Pelvic dysplasia Anomalous auricles Dysplastic middle phalanx of the fifth finger Single palmar crease Likelihood of DS when 6 features = 90%

Answer 742

Infants to 2 years Rear-facing car seat until 2 years of age or until child reaches the highest weight or height allowed by the car safety seat's manufacturer

Answer 743

Convertible seats and forward-facing seats w/ harnesses All children 2 years or older, or those younger than 2 years who have outgrowing rear-facing weight/height limit should use forward-facing safety seat w/ harness for as long as possible

Answer 744

Booster Belt-positioning booster seat until vehicle seat belt fits properly (typically when they reached 4' 9" in height and are between 8-12 years old in age)

Answer 745

Always use lap and shoulder seat belts in the rear seats for optimal protection

Answer 746

Tanner 1 - pre-pubescent Tanner 2 - earliest stages Tanner 3 - growth spurt Tanner 4 - peak of growth spurt Tanner 5 - Adult

Answer 747

2 years Tanner 4 - menarche

Answer 748

pre- puberty

Answer 749

Testes enlarge scrotal skin reddening w/ change in texture sparse growth of long, slightly pigmented pubic hair at bease of penis - Breast buds and papilla elevated Downy pigmented pubic hair along labia majora

Answer 750

Increase in penile length but minimal change in width "pencil penis" further scrotal enlargement pubic hari darker, coarse, covers greater area **Onset of growth spurt** - Breast mound enlargement darker, coarser pubic hair on mons, labia majora onset of growth spurt

Answer 751

Increase in penile length and width w/ development of glans further darkening of scrotal skin adult-type pubic hair w/ no spread to medial surface of thighs - Areola and papilla elevated to form a second mound above level of rest of breast adult-type of pubic hair w/ no spread to medial surface of thighs **menarche**

Answer 752

**Full adult** genitalia adult type hair w/ spread to medial surface of thighs, possible abdomen - Recession of areola to mound of breast Extension of pubic hair to medial thigh

Answer 753

Physical changes leading to sexual maturation and reproductive capability Puberty occurs during, but is not synonymous with, adolescense

Answer 754

Usually found in Tanner Stage 3 Usually resolves in 6-12 months

Answer 755

Most common cause of autism in either gender 1 in 4000 males 1 in 8000 females Occurs in all racial/ethnic groups Males: large forehead, prominent jaw, tendency to avoid eye contact, large testicles, large body habitus, learning and behavioral differences (hyperactivity, developmental disability common) Females: Significantly less common w/ fewer prominent findings, usually w/ less severe developmental issues Blood testing available for carrier state or for dx Antenatal dx possible w/ amnio, CVS or preimplantaion dx

Answer 756

XXY male Only males affected Low testicular volume, hip and breast enlargement, infetility Most developmental issues, language impairment most commonly Most common form of sex hormone aneuploidy 1 in 500-1000 some w/o sx Blood testing available for carrier state or for dx Antenatal dx w/ amnio, CVS, or preimplantaion dx

Answer 757

XO female Found in 1 in 2000-2500 females Short stature (5 feet or under) Usually evident by 5 years of age wide, webbed neck No ovaries Broad, shield-shaped chest Absent menses Infertility Often noticeable at birth Narrow high-arched palate Retrognathia low set ears edema of hands and feet Females who are classified as Turners mosaic w/ chromosonal changes in some but not all cells, typically w/ milder features High rate of spontaneous pregnancy loss in XO F fetus Blood testing for dx, antenatal dx w/ amnio, CVS, or preimplantaion dx

Answer 758

Follicular epidermal hyperproliferation w/ subsequent follicle plugging, excess subum production, presence of P. acnes, accompanying inflammation Leads to keratolytic and antibacterial tx Affects 80% of all teens w/ 20% having severe and subsequent scarring Affects skin areas where sebaceous follicles located: face, upper chest, back

Answer 759

Antibacterial against P. acnes as well as a comedolytic 2.5% as effective as higher strength and less likely to irritate skin Inexpensive OTC Most helpful in mild acne, usually w/ keratolytic acne wash w/ salicylic acid 2%

Answer 760

Keratolytic normalized hyperkeratinization Decreases cohesion between epidermal cells Increases epidermal turnover Significant antiinflammatory effect Indicated in all acne types Mild to moderate skin irritaion w/ redness and dryness - improves over time, expect 6 weeks therapy prior to noting improvement **Photosensitizing, use sunscreen**

Answer 761

Clindamycin, Erythromycin, Dapsone Antibacterial against P. acnes, anti-inflammatory Indicated in tx of mild to moderate acne Most effective for mild ane Less effective than oral abx for moderate-severe acne often used in combination w/ comedolytic such as benzoyl peroxide and/or tretinoin

Answer 762

Doxy, Minocycline, Erythro, TMP/SMX, Azithro (500 mg every 5 days) Antibacterial against P. acnes, anti-inflammatory Indicated for moderate inflammatory acne, usually when topical tx has been inadequate Once skin is clear (usually after 3 months of continuous tx), taper off slowly over a few months while adding topical abx agents Rapid discontinuation will result in return of acne Long-term tx or repeat tx usually needed

Answer 763

Reduction in adrogen levels, decreased sebum production Best suited for females w/ moderate to severe acne About 3 months of use prior to significant acne improvement With discontinuation, acne usually returns

Answer 764

Mechanism of action not well understood Likely inhibits sebaceous gland function Indicated for cystic severe acne that does not respond to other tx usual course of tx is 4-6 months discontinue when nodule count is reduced by 70% Repeat course only if needed after 2 months off drug Careful monitoring for mood destabilization and/or suicidal thoughts menthal health risk is low Prescriber and pt must be properly educated in use of drug and fully aware of adverse reactions profile: cheilitis, conjunctivitis, hypertriglyceridemia, xerosis, photosensitivity, potent teratogenicity Females of childbearing age must use two types of highly effective contraception 1 month prior to, during, and 1 month after use of isotretinoin iPLEDGE program is designed to prevent pregnancies in patients using isotretinoin by using iPLEDGE prescribers pharmacies, and signin iPLEDGE card

Answer 765

Tx: Topical retinoid alone often helpful Consider adding topical abx or benzoyl peroxide

Answer 766

20-100 comedones 15-50 inflammatory lesions 30-125 total lesions Tx: Oral abx with topical retinoid

Answer 767

\> 5 cysts \> 100 total comedones \> 50 total inflammatory lesions \> 125 total lesions Tx: Oral abx w/ topical retinoid if ineffective: Oral isotretinoin (Accutane) For large, painful cysts, consider intralesional corticosteroid injection

Answer 768

Accidental injury

Answer 769

For adolescent substance abuse Car - have you ridden in a car driven by someone who has been high/using drugs/ETOH? Relax - Do you ever use ETOH/drugs to relax, feel better about yoruself, fit in? Alone - Do you ever use alone? Forget - Do you ever forget things you did while using ETOH or drugs Friends - Do your family/friends ever tell you that you should cut down? Trouble - Have you ever gotten into trouble while using ETOH/drugs? 2 or more = serious problem

Answer 770

Male condom 18% failure rate

Answer 771

Contraception Pregnancy STI Substance abuse Mental health

Answer 772

Consider testing: Overweight or obese BMI \> 85th percentile + 2 or more risk fx Risk fx: Family hx of DM2 in first or second degree relative Race/ethnicity (other than Caucasian) Signs of, or condition associated w/, insulin resistance such as acanthosis nigricans, HTN, HL, PCOS, SGA Maternal DM or gestational DM **Initiate testing at age 10 years or at onset of puberty, early if puberty occurs earliet** **Frequency: every 3 years**

Answer 773

Low-fat dairy products Diet and nutritional counseling Screen children and adolescents w/ positive family hx of HL or premature (55 years or younger for men, and 65 years or younger in women) CVD or dyslipidemia. Screen children whose family hx is not known or those w/ other CVD risk factors such as overweight, (BMI 85th percentile or higher), obesity (BMI 95th percentile or higher), cigarette smoking, DM **Use a fasting lipid profile; if normal repeat in 3-5 years** First screening should take place after 2 years of age but no later than 10 years of age Primary tx of high TG or low HDL and overweight - _weight mgmt_ (diet and nutrition) For pts 8 years and older with LDL =\> 190 (or =\>160 if family hx of early heart disease or =\>2 risk fx, or =\>130 in DM), _pharmacologic intervention should be considered._ Target initially is LDL Can be as low as LDL

Answer 774

Scarlet fever Pathogen: S. pyogenes (GABHS) Tx: Penicillin first line PCN allergy: Azithro, clarithro, erithro

Answer 775

Roseola Agent: Human herpesvirus 6 (HHV-6) Often in children 6-24 months Febrile seizures in 10% of children affected Supported tx

Answer 776

**Rubella** Agent: Rubella virus **"3 day measles"** aka: **German Measles** Incubation period: 14-21 days Transmissible 1 week prior to rash onset and 2 weeks after rash appears Generally mild, self-limiting illness Greatest risk to unborn child, especially w/ first trimester exposure (_80% of congenital rubella syndrome_) _Notifiable disease,_ usually to state/public health authorities, laboratory confirmatin w/ _serum rubella IgM_

Answer 777

Measles Agent: Rubeola virus aka "Hard measles" Incubation period 10-14 days Transmissble for 1 week prior to onset of rash to 2-3 weeks after rash appears CNS and respiratory tract complications common Permanent neurologic impairment or death possible Supportive tx as well as intervention for complications Notifiable to state/public health Lab confirmation with serum rubeola IgM

Answer 778

Dx testing: Heterophil antibody test (Monospot), leukopenia w/ lymphocytosis and atypical lymphocytes Infectious Mononucleosis (IM) **Agent: Epstein Barr virus (human herpesvirus 4)** **Incubation period: 20-50 days** \>90% will develop a rash if given amoxicillin or ampicillin during the illness Potential for respiratory distress when enlarged tonsils and lymphoid tissue impinges on upper airway - _corticosteroids_ may be helpful Splenomegaly most often occurs between days 6-21 days after onset of illness _Avoid contact sport for at least 1 month_ d/t risk of splenic rupture

Answer 779

Hand, foot, and mouth disease Agent: Coxsackie virus A16 Transmission via oral-fecal or droplet Highly contagious Incubation period of 2-6 weeks Supportive tx Analgesia important School exclusion typically until all blisters have dried

Answer 780

Fifth's disease Agent: Human parvovirus B19 aka. erythema infectiosum Droplet transmission Leukopenia common Risk of hydrops fetalis w/ resulting pregnancy loss when contracted by woman during pregnancy Supportive tx Rash onset corresponds w/ disease immunity w/ patient Viremic and contagious prior to but not after onset of rash

Answer 781

Acute HIV infection Agent: Human immunodeficiency virus Most likely to occur in response to infection w/ large viral load Consult w/ HIV specialist concerning initiation of antiretroviral Tx

Answer 782

Kawasaki disease Agent: unknown Usually in ages 1-8 years M\>F Tx: IV immunoglobulin and PO ASA during acute phase Tx reduces rate of coronary abnormalities such as coronary artery dilation and coronary aneurysm Expert consultation and tx advice about ASA use and ongoign monitoring warranted

Answer 783

Iron-deficiency (IDA) Hemogram: Microcytic, Hypochromic, elevated RDW Most common in children ages 12-30 months Major contributors: depletion of birth iron stores (usually lasts 6 months), initiation of lower-iron diet later in infancy, early toddler stage - Most calories in first year of life shoud be from iron-enriched infant formula or breast milk w/ iron supplementation starting at ages 4-6 months, depending on amount of iron-fortified formula intake **cow's milk \> 16 oz/day after 12 months of age = most potent risk fx for IDA** **In child**

Answer 784

If breastfed, should receive 2 mg/kg/d of elemental iron starting age 1 month through 12 months If formula fed, iron supplements could be required

Answer 785

If \> 1/2 of feedings as human milk, should receive 1 mg/kg/day of supplemental iron starting at age 4 months until introduction of complementary foods (fortified cereals, legumes, red meats, dark green vegetables, vitamin C) If formula fed, receives enough iron from formula w/ introduction of complementary foos after ages 4-6 months

Answer 786

Supplemental iron should be continued for about 2 months after correction of anemia to replenish body stores **All children should be screened for IDA through hemoglobin measurement at age 1 year** Hg With milder anemia (Hg 10-11 g/dL), an alternative evaluation plan includes treating w/ iron for 1 month. A rise in Hg 1g or more after 1 month confirms IDA.

Answer 787

AAP: Breastfed: Vitamin D 400 IU/day starting first weeks of life Formula fed: If less than 800-1000mL/day of formula, supplement

Answer 788

Infants: 400 IU/day Children to adults age 70: 600 IU/day Age \> 70: 800 IU/day

Answer 789

Toddler (age 1-3): 500 mg/day Preschool, younger school age (4-8 years): 800 mg/day Older children to teens (9-18 years): 1300 mg/day

Answer 790

1 cup of milk/yogurt = 250 mg Ca 1 cup of collards = 357 mg Ca 1 cup of black-eyed peas = 211 mg Ca 3 oz of tofu = 163 mg ca 1 cup cottage cheese 1% milk fat = 138 mg Ca 1 cup of soy milk = 93 mg Ca 1 oz of almonds (24 nuts) = 70 mg of Ca

Answer 791

Sx must be present before age 12 Impairment must be present in at least 2 settings must have evidence of functional interference (socially, academically, or in extracurricular activities)

Answer 792

Inattention: 5 or more must occur often: Fails to give close attention to details or makes careless mistakes in schoolwork, work, other activities Difficulty sustaining attention in tasks, play activities does not seem to listen when spoken to directly Does not follow through on instructions or fails to finish schoolwork, chores, or duties Difficulty organizing tasks and activities Easily distracted by extraneous stimuli Forgetful in daily activities

Answer 793

Fiver or more of the following must occur often: Fidgets w/ hands or feets or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs about or climbs excessively in situations when inappropriate Difficulty playing or engaging in leisure activities quietly Acts "on the go" or acts as if "driven by a motor" Talks excessively Blurts out answers before questions are completed Difficulty waiting turn Interrupts or intrudes on others

Answer 794

**Laryngotracheobronchitis** **Stridor** Caused by upper airway obstruction - getting air in more of a problem than getting air out Characteristic sound heard on inspiration Viral, allergic in origin Most common 6 months to 5 years **"Steeple" sign on frontal chest radiograph** **Tx Supportive** **Systemic corticosteroids**

Answer 795

Stridor - upper airway obstruction Acute onset from mechanical obstruction, most common in toddlers Tx: removal

Answer 796

Stridor - upper airway obstruction Usually bacterial Most often in older child or adult Usually presents w/ "hot potato" voice Difficulty swallowing Trismus Contralateral uvula deviation Tx: Attention to airway Prompt ENT consult Antimicrobial therapy Usually inpatient admission Perhaps surgical intervention

Answer 797

Bacterial origin (most often H. influenzae type B) Most often in children age 2-7 years Abrupt onset of high-grade fever, sore throat, dysphagia, drooling Dx: Attention to airway maintenance Thumb sign on lateral soft-tissue radiograph of neck Prompt ENT consult Antimicrobial therapy Usually inpatient admission

Answer 798

Often called **"disease of the happy wheezer"** Milder ill child **3 months to 3 years** Most viral etiology Most often from RSV less commonly from influenzae or adenovirus short-term acute illness w/ wheezing lasting about **3 weeks** Most serious in early infancy **(** Nearly all episodes occur between Novemenr and April Tx: Supportive Little evidence that inhaled bronchodilateros or inhaled/systemic corticosteroids are helpful Palivizumab (Synagis) often used to prevent RSV in fection in premature infants (first RSV season in infants born at

Answer 799

Viral etiology Short-term, self-limiting Tx: Supportive Inhaled beta-agonist Oral anti-inflammatory tx

Answer 800

Acute bronchiolitis Acute bronchitis Asthma

Answer 801

Croup Foreign body Congenital obstruction Peritonsillar abscess Acute epiglottitis

Answer 802

Sx = Nighttime awakenings 0 SABA = No interference w/ normal activity Exacerbations requiring oral corticosteroids 0-1/year Step 1 Tx

Answer 803

Sx \> 2 days/week Nighttime awakenings 1-2x/month SABA \> 2 days/week but not daily Minor activity limitation 2 or more exacerbations in 6 months requiring oral corticosteroids or 4 or more wheezing episodes/year lasting \> 1 day Tx Step 2

Answer 804

Daily sx Nighttime awakenings 3-4x/month Daily SABA Some limitation to normal activity 2 or more exacerbations requiring oral prednisone in 6 months or 4 or more episodes/year of wheezing lasting \> 1 day Tx: Step 3

Answer 805

Sx throughout the day Nighttime awakenings : \> 1x/week SABA several times a day 2 or more exacerbation requiring oral prednisone in 6 months or 4 or more episodes of wheezing in 1 year lasting more than 1 day Tx: Step 3 and consider short course of corticosteroids

Answer 806

Low-dose ICS SABA PRN Alternative: Cromolyn Montelukast

Answer 807

Medium-dose ICS SABA PRN

Answer 808

Medium-dose ICS + LABA or Montelukast SABA PRN

Answer 809

High-dose ICS + LABA or Montelukast SABA PRN

Answer 810

High-dose ICS + Montelukast or LABA AND Oral Systemic Corticosteroids

Answer 811

Sx = Nighttime awakenings = SABA = No interference w/ activity Normal FEV1 between exacerbations FEV1 \> 80% predicted FEV1/FVC \> 85%

Answer 812

sx \> 2 days/week but not daily Nighttime awakenings 3-4x/month SABA \> 2 days/week but not daily Minor activity limitation FEV1 =\>80% predicted FEV1/FVC ration \> 80%

Answer 813

Daily sx Nighttime awakenings \> 1x/week but not nightly Daily SABA Some activity limitation FEV1 60-80% predicted FEV1/FVC = 75-80%

Answer 814

Sx throughout day Nighttime awakenings often 7x/week SABA several times per day Extremely limited activity FEV1 FEV1/FVC

Answer 815

Low-dose ICS **Alternative** Cromolyn LTRA Nedocromil Theophylline

Answer 816

Low-dose ICS + LABA or LTRA or Theophylline **Alternative** Medium-dose ICS

Answer 817

Medium dose ICS + LABA **Alternative:** Medium dose ICS + LTRA or Theophylline

Answer 818

High-dose ICS + LABA **Alternative:** High-dose ICS + LTRA or Theophylline

Answer 819

High dose ICS + LABA + Oral systemic corticosteroid **Alternative** High-dose ICS + LTRA or Theophylline + Oral systeic corticosteroid

Answer 820

Resistance to passive movement Best felt at elbow, wrist, neck Found in Parkinsons

Answer 821

Dx of herpes Tzanck smear will reveal giant multinucleated cells

Answer 822

heredity family hx female gender

Answer 823

May hemorrhage send to ER

Answer 824

renal conditions e.g. renal artery stenosis and renal failure

Answer 825

Avoid high potassium foods Treat inpatient until edema and HTN are under control Restrict protein in presence of azotemia and metabolic acidosis Fluid intake should be restricted to only the amount patient requires to replace lost fluids

Answer 826

Divide person's weight by height squared

Answer 827

Topical hydrocortisone can relieve pain, itching, inflamm Stool softener reduce straining during defecation Local analgesic spray, suppository, or cream provide pain relief

Answer 828

Decreased peristalsis from progesterone Physiologic change during pregnancy Results in GERD and constipation

Answer 829

8 years range 8-13 years

Answer 830

9-14 years

Answer 831

Idiopathic in 85% or higher Most common puberty disorder Continuous GnRH agonist analog option to delay progress - \> 13 years Multiple fx: nutrition (low weight), hormonal, genetic (Turner syndrome XO), others

Answer 832

Idiopathic in CNS tumors most often implicated - \> 14 years Multiple fx: nutritional, hormonal, genetic, others

Answer 833

Congenital lacrimal duct obstruction

Answer 834

Adult form of rickets Poor bone formation in children and softening of bones in adults Causes spine to bend and legs to become bowed Result of Calcium and Vitamin D deficiency

Answer 835

transvaginal U/S

Answer 836

fever increased WBC tachycardia peritoneal signs advanced age

Answer 837

if burns are \> 10% of TBSA in age 50 \> 20% TBSA in all other ages burns over a joint circumferential burns

Answer 838

Hyperactive bowel sounds Rush of gurgling, tinkling sounds Typically loud

Answer 839

older age at onset cerebellar involvement male gender persisting deficits in brain stem short first inter-attack interval

Answer 840

Misalignment of one or both eyes (cross-eyed) Infants younger than 20 weeks may have intermitten esotropia, usually resolves spontaneously

Answer 841

discrete narrowing of the aorta just opposite the site of the ductus arteriosus

Answer 842

gastric bypass Limited sun exposure renal disease use of sunscreen use of phenobarbital hepatic disease

Answer 843

swelling behind knee cystic swelling in popliteal space if bursa ruptures, acute swellling of lower leg might mimic DVT

Answer 844

SSRIs, TCAs, CBT Avoid MAOI - potential for severe food interactions and HTN crisis

Answer 845

Infants: ampicillin + 3rd gen ceph Adults: 3rd gen ceph + chloramphenicol Adults \> 50: Amox + 3rd gen ceph

Answer 846

CT - computerized tomography

Answer 847

40% risk of latent disease 10% risk of clinically significant disease 3% risk of dying from prostate ca

Answer 848

Myoclonic and atonic seizures: Clonazepam Simple, Complex partial: carbamazepine, phenytoin, divalproex sodium, valproic acid

Answer 849

Erythromycin

Answer 850

Ampicillin

Answer 851

Trimethoprim-Sulfamethoxazole

Answer 852

Metronidazole

Answer 853

urinary urgency, hesitancy dysuria incontinence

Answer 854

Ixodes tick bite infected w/ Borrelia burgdorgeri

Answer 855

can cause deafness Teratogen

Answer 856

Teratogen Can cause cardiac defects

Answer 857

Teratogen Can cause CVAs and mental retardation

Answer 858

Contraindicated in the third trimester Can cause hemolysis in utero w/ resulting hyperbilirubinemia

Answer 859

No pathogen 4% Virus 70% Bacteria + virus 66% **Strep pneumo (gram +) in 49% of bacterial AOM** - Treatment target. Consider drug resistance risk. Mechanism of resistance: alters protein binding sites within bacterial cells. Low rate of 10-20% spontaneous resolution w/o abx **H. influenzae (Gram - bacillus) 29%** - Resistance via beta-lactamase production. Moderate rate of 50% spontaneous resolution w/o abx **M. catarrhalis (Gram - cocci) 28%** - Resistance via beta-lactamase production. Nearly **ALL** resolve w/o abx

Answer 860

Appendicitis Pain in RLQ w/ passive right hip extension

Answer 861

tests MCL Bend knee INward

Answer 862

tests LCL bend knee OUTward

Answer 863

RLQ pain illicited w/ LLQ pain palpation + appendicitis

Answer 864

r/t obstruction of portal blood flow which increases portal venous pressure resulting in: splenomegaly Ascite collateral venous channels para-umbilical and hemorrhoidal veins Cardia of the stomach and into esophagus

Answer 865

absence of pain sensation

Answer 866

decreased sensitivity to pain

Answer 867

increased sensitivity to pain

Answer 868

absence of touch sensation

Answer 869

Detachment of vitreous from the retina

Answer 870

pulmonary valve stenosis

Answer 871

aortic valve stenosis

Answer 872

ventricular septal defect

Answer 873

double by 6 months Triple by 1 year

Answer 874

prostate/cervix rectum urinary bladder posterior pelvic wall

Answer 875

all pelvic viscera deep part of perineum gluteal region

Answer 876

RR at rest is =\> 60 bpm

Answer 877

have pt squeeze around inserted fingers for as long as possible full strength = snug compression for 3 or more seconds

Answer 878

produced by the placenta supports progesterone syntehesis in the corpus luteum, effectively preventing early embryo from being lost to menstruation

Answer 879

Adhesive capsulitis

Answer 880

difficulty speaking and understanding words and unable to read/write

Answer 881

speech is confluent, slow few words laborious effort inflection and articulation are impaired but words are meaningful, w/ nouns, transitive verbs, and important adjectives small grammatical words are often dropped

Answer 882

word-findingn difficulties struggles to find right words for speaking and writing

Answer 883

speech is fluent, often rapid, voluble, and effortless Inflection and articulation are good BUT sendtences lack meaning and words are malformed (paraphasias) or invented (neologisms) Speech may be totally incomprehensible

Answer 884

**Mild:** mental age 8-12 years **Moderate:** trainable up to 3-7 years IQ 35-55 **Severe:** IQ between 25-40, limited communication, capable of learning certain self-care activities, and mental age of toddler **Profound:** IQ

Answer 885

Tetralogy of Fallot

Answer 886

disappears by 4 months

Answer 887

Disappears by 12 months or when walking

Answer 888

Golfer's elbow

Answer 889

tibiotalar joint assessed through dorsi and plantar flexion

Answer 890

extend both arms and palms face upward for 20-30 sec forearm drifts downward = corticospinal lesion in the contralateral hemisphere forearm drifts upward = lesion in the cerebellum

Answer 891

right shoulder or right posterior chest

Answer 892

asphyxia hypoglycemia hypocalcemia

Answer 893

respiratory distress syndrome apnea patent ductus arteriosus w/ left to right shunt infection

Answer 894

absence or loss of control of voluntary muscle movement

Answer 895

involuntary muscle spasms and twisting of limbs

Answer 896

presence of involuntary muscle movement such as tics or chorea can be seen in children w/ rheumatic fever

Answer 897

impaired ability to adjust one's body position noted in Parkinson's

Answer 898

abnormal or unpleasant sense of touch

Answer 899

Risk of Listeria, Salmonella, toxosplasmosis

Answer 900

touch thumb to each of the other fingertips

Answer 901

meconium aspiration asphyxia

Answer 902

ventricular septal defect overriding aorta pulmonary stenosis right ventricular hypertrophy

Answer 903

20 deciduous teet between 6 months and 5 years of age Permanent teeth begin to erupt at 6 years of age when deciduous teeth begin to fall out All 32 permanent teeth usually erupt by late adolescence

Answer 904

Unilateral lesions e.g. congenital diaphragmatic hernia

Answer 905

Human placental lactogen

Answer 906

columnar epithelium cover most or all of cervix vaginal adenosis circular collar or ridge of tissue, of varying shapes, between the cervix and vagina

Answer 907

on the manubrium and body of sternum

Answer 908

loss of voice accompanies disease affecting larynx or its nerve sypply

Answer 909

refers to less severe impairment in volume, quality, ptich of voice

Answer 910

pelvic pain that lasts \> 6 months w/o response to tx

Answer 911

acute pancreatitis

Answer 912

tennis elbow

Answer 913

Moderate or severe bulging of TM OR new onset of otorrhea not r/t OE w/ otalgia - Mild bulging TM AND recent (within 48 hours) onset of ear pain OR intense TM erythema w/ otalgia

Answer 914

**Nonsevere:** Mild otalgia or Fever **Severe:** Moderate to severe otalgia or Otalgia \> 48 hours or Fever 39 C / 102.2 F or higher

Answer 915

Analgesia w/o abx Indicated if low risk for adverse outcome w/o abx high rate of spontaneous AOM resolution Watchful waiting only appropriate for child 6 months of age and older w/ non-severe illness for unilateral AOM If used, follow up must be ensured w/ ability to start abx within 48-72 hours if child fails to improve or worsens 80% of children will be better in 7-10 days 70% within 2-3 days

Answer 916

Amoxicillin 80-90 mg/kg/day in 2 divided doses OR Amox-Clav 90 mg/kg/d amox and 6.4mg/kg/d of clav in 2 divided doses PCN allergy: Cefdinir 14 mg/kg/day in 1 or 2 doses Cefuroxime Cefpodoxime Ceftriaxone 50 mg IM for 1-3 days

Answer 917

Amox clav 90 mg/kg/d amox w/ 6.4 mg/kg/d of clav in 2 divided doses Ceftriaxone 50 mg IM daily x 3 days **PCN allergy:** Ceftriaxone 50 mg IM daily x 3 days Clindamycin 30-40 mg/kg/d in 3 divided doses w/ or w/o 3rd gen ceph Consider tympanocentesis, referral to specialist

Answer 918

Avoid 1st generation and older 2nd generation cephalosporins minimal risk for reaction 1% cross-allergy risk Note: ceftriaxone has stronger strep pneumo coverage than other cephalosporins

Answer 919

fluid in middle ear w/o infection formerly known as serous otitis Watchful waiting in majority 75-90% will resolve within 3 months w/o specific tx Consider audiologic eval if OME persists for at least 3 months, if concerns for hearing, speech, or language Tympanostomy and/or adenoidectomy reduced time w/ OME and improved hearing in short term but were associated w/ expected risk Persistent OME is the most common cause of TEMPORARY speech delay in early childhood

Answer 920

3-5% Normal BP, pulse quality, HR, turgor, fontanels, eyes (tears present), cap refill ( Slightly dry lips thick saliva Slighly decrease urine output normal thirst to slightly increaseed

Answer 921

6-9% Normal BP Normal to slightly decreaed pulse quality Normal to increased HR Turgor recoil Slightly depressed fontanels Dry lips and oral mucosa Slighly sunken eyes, decreased tears Delayed cap refill (1.5-3 seconds) Normal to fatigued/restless/irritable mental status Decreased urine output Moderately increased thirst

Answer 922

\> 10% Normal to reduced BP Moderately decreased pulse quality Increased HR (sometimes brady) Recoil \> 2 seconds/tenting turgor Depressed fontanels Very dry lips, oral mucosa Deeply sunken eyes, tears absent Delayed cap refill \> 3 seconds Apathetic, lethargic, unconscious Minimal urine output Very thirsty to too lethargic to assess

Answer 923

Rehydration tx N/A sips of fluid frequently as tolerated to maintain circulating volume/hydration status **Replacement for ongoing losses:** \> 10 kg: 120-240 ml for each loss

Answer 924

Rehydration Tx: ORT w/ ORS 50-100 mL/kg over 3-4 hours best tolerated in frequent, small volumes supply in office to demonstrate ability tolerate oral tx **Replacement for ongoing losses:** \> 10 kg: 120-240 ml for each loss

Answer 925

Consider premedication w/ 5-HT3 antagonist such as Ondansetron to minimize risk of further upper GI fluid loss

Answer 926

Lactated Ringers preferred over NS may use NS if LR not available Bolus 20 mL/kg until improvement then 100 mL/kg over 4 hours **Replacement for ongoing losses:** \> 10 kg: 120-240 ml for each loss If unable to drink, give through NG tube or give D5W1/4 NS w/ K+ 20 meq + IV

Answer 927

Tx w/ empiric parenteral abx admit to hospital for neonatal sepsis eval

Answer 928

CBC w/ diff, blood culture, U/A and C&S via transurethral cath or suprapubic tap As indicated: LP for CSF analysis and culture, CXR, stool culture, fecal WBC count Note: tachypnea: PNA until proven otherwise

Answer 929

Presumed bacterial: Amox 90 mg/kg/d in 2 doses Alternative: Amox-Clav Presumed atypical: Azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/d day 2-5) Alternative: Clarithro (15mg/kg/d in 2 doses x 7-14 days) Erythromycin (40mg/kg/d in 4 doses)

Answer 930

Amox 90 mg/kg/d in 2 divided doses, max 4g/d May add macrolide to beta-lactam abx if unsure if atypical or not Alternative: Amox clav Presumed atypical: Azithro 10 mg/kg/d on day 1, 5 mg/kg/d day 2-5 Azithro max of 500 mg day 1, 250 mg day 2-5 Alternative: Clarithro/Eryhtro. Doxy if \> 7 years old

Answer 931

Oseltamivir **5 years and older:** Oseltamivir Zanamivir if children 7 years old or older Peramivir IV Zanamivir availabe for compassionate use

Answer 932

Amox 20-40 mg/kg/d x 3 doses Bactrim 6-12 mg TMP, 30-60 mg SMX per kg in 2 doses Cefixime 8 mg/kg/d in 2 doses Cefpodoxime 10 mg/kg/d in 2 doses Cefprozil 30 mg/kg/d in 2 doses Cephalexin 50-100 mg/kg/d in 4 doses Loracarbef 15-30 mg/kg/d in 2 doses

Answer 933

Uncomplicated viral URI: nasal sx and/or cough, nasal discharge progresses from clear to purulent to w/o abx, usually within 10 days; Fever early in illness assoc. w/ constitional sx such as headaches, myalgias that resolve in 24-48 hours as the respiratory sx worsen When ABRS: (1 or more) Worsening URI course, such as double sickening (acute worsening of respiratory sx or new fever at day 6-7 of URI) Persistence of URI sx w/o improvement after 7-10 days, including nasal discharge, day time cough, bad breath, fatigue, headache, decreased appetite Acute onset of T: 102.2, purulent nasal discharge, ill appearance for 3-4 days

Answer 934

Acute URI w/ persistent illness or daytime cough \> 10 days w/o improvement: Abx or 3 days observation Worsening course, double sickening, severe onset fever, purulent nasal discharge \> 3 consecutive days: Abx tx Contrast CT of sinuses and/or MRI w/ contrast should be obtained if child is supected of having CNS or orbital complications Likely pathogens: S. Pneumo (30%) - decreased d/t pneumococcal vaccine Non-typeable H. influenzae (30%) M. Catarrhalis (10%) Sterile (no pathogen isolated, viral) 25% **Abx:** **Initital:** Amoxicillin 80-90 mg/kg/d w/ or w/o Clav **If no improvement or worse in 72 hours:** HD amox-clav **If initial tx HD amox-clav and no improvement in 72 hrs:** Clindamycin AND cefixime or Linezolid and cefixime or Levofloxacin

Answer 935

aka innocent/functional **Gr 1- 3/6 early to midsystolic murmur** heard best at **LSB** but usually audible over precordium **No radiation** beyond precordium Softens or **diseappears w/ STANDING** Increases in intentsity w/ activity, fever, anemia S1 S2 intact normal PMI Etiology: flows over aortic valve, heard in 80% of thin, healthy adults if examined in soundproof room Asymptomatic

Answer 936

Gr 1-4/6 **systolic** murmur **crescendo-decrescendo** heard best at **2nd RICS, apex** softens w/ standing **radiates** to carotids may have diminished S2 slow-filling carotid pulse narrow pulse pressure Loud S4 heaving PMI later peak = greater stenosis In younger adults: congential bicuspid valve In older adults: calcific, rheumatic in nature **Ominous signs: dizziness, syncope = severe decreased CO**

Answer 937

Gr 2-3/6 high **systolic** ejection murmur heard best at **2nd RICS** **Full carotid upstroke, not delayed** no S4 no symptoms **Benign** thickening and/or calcification of aortic valve leaflets No change in valve pressure gradient AKA: **"50 over 50" murmur** - foundin \> 50% of those over 50y

Answer 938

Gr 1-3/4 **high-pitched blowing _diastolic_** murmur heard best at **3rd LICS** May be enhanced by forced expiration, leaning forward Usually w/ **S3** **Wide pulse pressure** Sustained thrusting apical pulse More common in MEN usually from rheumatic heart disease Occassionally d/t tertiary syphilis

Answer 939

Gr 1-3 **low-pitched late diastolic** murmur heard est at **apex**, localized short **crescendo-decrescendo** rumble like a bowling ball rolling down alley or distant thunder Often w/ opening snap, accentuated S1 in mitral area Enhanced by left lateral decubitus, squat, cough, immediately post Valsalva **Nearly all rheumatic** in origin Protracted latency period, then **gradual decrease in exercise tolerance** leading to rapid downhill course d/t **low CO** **AF common**

Answer 940

Gr 1-3/6 **systolic ejection murmur** at the **pulmonic** area **Widely split S2**, right ventricular heave Typically w/o sx until middle age then present w/ **HF** Persisten ostium secundum in mid-septum Will resolve w/ ASD correction

Answer 941

**Narrow splitting S2** murmur of **tricuspid regurgitation** **Report of SOB** nearly universal Seen w/ **RVH**, as identified by ECG, echo Secondary PH might be consequence of Redux (fen-phen) use

Answer 942

Gr 1-4 **high-pitched blowing systolic murmur** Often extending beyond S2 Sounds like long "haaa" "hooo" Heard best at **RLSB** **Radiates to axilla** Often **laterally displaced PMI** Decreased w/ standing, valsalva maneuver Increased by squate, hand grip Found in ischemic heart disease, endocarditis, RHD W/ RHD, often w/ other valve abnormalities such as AS, MS, AR

Answer 943

Gr 1-3/6 late **systolic** **crescendo** murmur **honking quality** heard best at **apex** **follows midsystolic click** click moves forward to earlier systole w/ Valsalva or standing, resulting in a longer-sounding murmur W/ hand grasp or squat, click moves back further into systole, resulting in shorter murmur Often seen w/ **minor thoracic deformities** (e.g. pectus excavatum, straight back, and shallow AP diameter. Chest pain somimes present but there is question at whether MVP is cause)

Answer 944

Prosthetic cardiac valve of prosthetic material used for cardiac valve repair Previous IE Congenital heart disease Unrepaired cyanotic CHD including shunts/conduits Completed repaired heart defet w/ prosthetic material/device, during first 6 months after procedure Repaired CHD w/ residual defects at site or next to site of prosthetic pathc/device (which inhibit endotheliazation) Cardiac transplant

Answer 945

Give **30-60 minutes** before procedure **Adults:** Amox 2 g Ampicillin 2 g IM or IV Clindamycin 600 mg Cephalexin 2 g Azithro/Clarithro 500 mg Cefazolin or ceftriaxone 1 g IM/IV Clindamycin 600 mg IM/IV **Children:** Amox 50 mg/kg PO Ampicillin 50 mg/kg IM or IV Cefazolin or Ceftriaxone 50 mg/kg IM/IV Clindamycin 20 mg/kg Cephalexin 50 mg/kg Azithro/Clarithro 15 mg/kg Cefazolin or ceftriaxone 50 mg/kg IM or IV Clindamycin 20 mg/kg IM or IV

Answer 946

**MANAGEMENT** Rheumatology referral PT/OT referral **Start DMARD therapy ASAP after dx** **Lab testing prior to therapy** CBC ESR CRP aminotransferase BUN Creatinine **NSAIDs until DMARD has taken effect** Example: Hydroxychloroquine (HCQ) 400 mg tablet, take 1 tablet orally with food or milk daily. Sulfasalazine (SSZ) enteric coated 500 mg tablets, take 1 tablet orally daily x 1 week, then 1 tablet twice a day for the second week, 2 tablets in the morning and 1 tablet at night for third week, then 2 tablets twice a day for the fourth week. **May use OTC Naproxen 500 mg orally twice a day until DMARD has taken effect. Discontinue as soon as possible.** HCQ commonly results in clinical improvement within 2-3 months, maximum effects may required up to 4-6 months. If anadequate response at 3 months, add an alterantive DMARD, usually MTX, or combine HCQ with other DMARDs such as SSZ and MTX. MTX dosing: 7.5 mg once weekly orally then adjust dose gradually not to exceed 20 mg once weekly. OR start at 10-15 mg once weekly, then go up by 5 mg every 2-4 weeks to a maximum to 30 mg once weekly. **Nonpharmacological tx/patient education:** Rest joint when inflamed but alternate rest periods w/ exercise to avoid loss of ROM/muscle atrophy Ensure adequate nutrition/dietary intake Stress reduction

Answer 947

Nonpharm: exercise, weight loss, PT, orthoses, brace/splint, joint protection, moist superficial heat, psychosocial support **Pharm:** APAP PRN 650 every 4-6 hours do not exceed 3250 mg/day APAP 1000 mg every 6 hours do not exceed 3000 mg/day If inflammation/APAP inadequate: Try Naproxen first, if no effect after 2-4 weeks on max dose, try other NSAID Naproxen 500 to 1000 mg daily in 2 divided dose Etoricoxib 30-60 mg once daily Diclofenac Celecoxib Ibuprofen 400-800 mg 3-4x/day max 3.2g/day Obtain CBC, Bun, Creat and LFTs at least annually on pts on chronic NSAIDs May add Capsaicin as adjunct to NSAIDs Capsaicin patch - apply to affected area 3-4 x/day for 7 days, patch may remain in place for up to 8 hours

Answer 948

Monitor BP Monitor for edema Encourage non-pharm measures Choose lowest effective dose Modulate antiHTN tx and diuretic tx as needed to maintain target BP/weight Change NSAIDs as needed to one w/ lower CV risk

Answer 949

Biceps motor Biceps reflex Sensation lateral arm at/above elbow

Answer 950

Thumb motor Brachioradialis reflex Sensation to forearm, thumb side

Answer 951

Motor: 3rd finger Triceps reflex sensation to middle finger

Answer 952

Motor: 4th finger Lateral sides of hand sensation

Answer 953

Motor: 5th finger Sensation medial side of forearm

Answer 954

Acute: tx within 24 hours First line: NSAIDs Naproxen 500 mg BID or Indomethacin 50 mg TID x 5-7 days Avoid ASA - paradoxical effect on serum urate If cannot take NSAID: Colchicine 1.5 - 1.8 mg in 2-3 divided doses in first 24 hours then taper If cannot take NSAID/Colchicine: intraarticular corticosteroid injection If not candidate for joint injection, oral prednisone 30-50 mg until sx resolve then taper

Answer 955

Xanthine oxidase inhibitor (COI) tx w/ Allopurinol or febuxostat (Uloric) = first line urate-lowering tx Low-dose NSAID tx also appropraite for gout attack prophylaxis Serum urate should be lowered w/ target of Pegloticase (Krystexxa) is appropriate for pts w/ severe gout Pharmacological antiinflammatory prophylaxis is recommended for all gout pts when urate lowering tx is initiated, continue if clinical evidence of continuing gout disease and/or urate tarte has not yet been achieved

Answer 956

Ophthalmoscopic exam: vein is twisted on the distal side of the artery

Answer 957

vein appears to stop abruptly on either side of artery

Answer 958

vein appears to cross beneath artery

Answer 959

vein appears to taper down either side of artery

Answer 960

pupils appear small and irregularly shaped accommodate but do NOT react to light

Answer 961

dilated pupil fixed to light and near accommodation ptosis and lateral deviation of eye usually present

Answer 962

Persistent infection w/ high risk HPV subtypes 16 or 18

Answer 963

lateral decubitus

Answer 964

Classic clinical presentation: cough and daily production of mucopurulent and tenacious sputum lasting months to years acquired disorder of major bronchi and brondhoiles Eval: CBC w/ diff, immunoglobulin quant, sputum culture, xray, PFTs Exacerbations caused usually by acute bacterial infections

Answer 965

**Step 1** Target fasting plasma glucose **FPG target: 70-130 mg/dL** HS basal insulin - start 10 units or 0.2 units/kg Increase dose 2 units every 3 days until FPG is 70-130 mg/dL Can increase by 4 units every 3 days if FPG \> 180 **Step 2** Target premeal glucose (1 target at a time) 70-130 mg/dL If pre-lunch \> 130, start 4 units bolus insulin before breakfast If pre-supper glucose \> 130, start 4 units bolus insulin before lunch OR add/increae morning NPH, detemir, glargine If bedtime glucose is above target (\>140), start 4 units bolus insulin before supper OR incrase evening NPH, detemir, or glargine \>\> **For all above** Increase bolus insulin by 2 units every 3 days Once insulin dose \> 10 units, egin to change insulin dose by 10-20% **Step 3** If A1C not at goal, target post-prandial glucose w/ bolus premeal insulin 2-hour post-prandial glucose target

Answer 966

Occurs in 30% of pts tx for primary syphilis Occurs in 70% of pts tx for secondary syphilis within 24 hours of tx The Jarisch-Herxheimer reaction is an acute febrile reaction that usually occurs within the first 24 hours after any therapy for syphilis. The fever may be accompanied by headache, myalgias, rigors, sweating, hypotension, and the worsening of rash if initially present These symptoms often resolve without intervention within 12 to 24 hours

Answer 967

CSF w/ IgM antibody for WNV WNV: viral infection causing febrile illness, rash, arthritis, myalgias, weakness, lymphadenopathy, meningoencephalitis

Answer 968

Multiple cognitive deficits, memory impairment one or more of the following: aphasia, apraxia, agnosia, disturbance of executive function

Answer 969

M: 37-49% F: 36-46%

Answer 970

Abd CT w/ oral and IV contrast Identifies bowel wall thickening, complications such as fistulas and abscesses

Answer 971

Cough, maldigestion, excessive NaCl excretion in sweat and saliva Most common genetic disorder of the white population

Answer 972

leiomyomas endometriosis malignancy of uterus, ovary, or colon adhesions interstitial cystitis

Answer 973

Progressive loss of effectiveness To minimize in steroid tx of eczema, use for 10 days then allow for 4 treatment free days

Answer 974

Brand: Starlix Meglitinide analog short-acting oral antidiabetic stimulates insulin release glucose dependent quick onset but should not be taken if meal is skipped

Answer 975

Lesions usually subside w/o tx 6-9 months refer to derm if multiple lesions are unresponsive to tx

Answer 976

should NOT be used for pts w/ bulimia can induce further binging or seizures in pts w/ bulimia (Wellbutrin)

Answer 977

APAP best choice Avoid ASA in children w/ viral illness d/t Reye syndrome Avoid Ibupofen in varicella d/t risk of necrotizing fasciitis

Answer 978

low plasma glucose parasympathetic and sympathetic symptoms Relief w/ ingestion of carbohydrates

Answer 979

Colchicine interacts w/ B12 by decreasing absorption Does not interact w/ iron therapy

Answer 980

Antacids Caffeine Fluoroquinolones Tetracyclines some antihypertensives thyroid hormones histamine-2 receptor antangonists

Answer 981

Penicillin VK Erythromycin

Answer 982

nervousness, insomnia, decreased sense of smell and taste, ringing in the ears mild skin rash - if rash spreads or turns purple, immediate medical attention should be sought

Answer 983

Laparoscopy

Answer 984

T0 = no evidence of primary tumor T1 = Tumor 2 cm or less in greatest dimension T2 = Tumor \> 2 cm but no more than 5 cm in greatest dimension T3 - Tumor \> 5 cm in greatest dimension

Answer 985

Fungal nail infection

Answer 986

Bacterial infection of the sebaceous glands of the acilla by Gram + S. aureaus Marked by flare ups and resolution

Answer 987

Average weight loss from gastric band: 40-60% of body weight About 80% of pts lose a great deal of weight w/o major complications and maintain loss long-term Expected weight loss form gastric bypass: 70-80% of excess body weight

Answer 988

halos around light unilateral ocular pain blurred vision lacrimation photophobia frontal ipsilateral h/a N&V

Answer 989

Only if clinician plans to offer tx for positive results pts w/ gastric MALT lymphoma, active peptic ulcer disease, OR past hx of documented peptic ulcer test and treat stratedgy effective for pts under age 55 w/ uninvestigated dyspepsia w/o alarm features Alarm features: bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia recurrent vomiting, family hx of GI ca, previous esophagogastric malignancy **Test of choice:** **Test for active infection w/ stool antigen or urea breath test** Serology has low value as it cannot differentiate between past or current infection **Endoscopy bx** For pts who are undergoing dx endoscopy and are found to have an ulcer and those who require endoscopy to follow up a gastric ulcer, or for dx/f/u of suspected MALT lymphoma - biopsy urease testing in pts not taking abx or PPIs (if taking, will interfere w/ test) **RE-TEST** Recommended to confirm eradication at least four weeks after treatment w/ stool and/or breath test

Answer 990

**Clindamycin** FDA approved to treat serious infections d/t S. aureus C-diff associated, uncommon, but more so than other agents **Tetracyclines** Doxy/Mino FDA-approved for staph Not recommended during pregnancy Not recommneded for children Unknown activity against A. strep **TMP/SMX** Not FDA-approved to treat any staph infection May not provided coverage for A strep (common cause of cellulitis) Not recommended for women in third trimester of pregnancy Not recommended for infants **Rifampin** Use only in combo w/ other agents Drug-drug interactions common **Linezolid** Consult w/ an ID FDA-approved for complicated skin infections including MRSA Assoc. w/ myelosuppresion, neuropathy, lactic acidosis w/ prolonged tx **IMPORTANT** MRSA is resistant to all currently available beta-lactams (PCN, ceph) Fluroquinolones (cipro, levo) and macrolides (erythro, clarithro, azithro) are not optima flr tx of MRSA SSTI d/t resistance

Answer 991

**No PCN allergy w/o hx of macrolide tx:** Standard dose PPI + Clarithro 500mg BID + Amox 1000 mg BID x 10-14d **PCN allergy w/o hx of macrolide tx or unable to tolerate bismuth quadruple tx:** Standard dose PPI + Clarithro 500mg BID + Metronidazole 500 mg BID x 10-14d **PCN allergy quad tx:** Bismuth subsalicylate 525 mg QID, Metronidazole 250 mg QID, Tetracycline 500 mg QID, Ranitidine 150 mg BID (or standard dose PPI QD-BID) x 10-14d **PPI examples:** Omeprazole 20 mg BID, Lanzoprazole 30 mg BID

Answer 992

Benign tumor of endothelium, local proliferative process Perhaps genetic mutation of epithelial regulation Often not present at birth, rapid growth from first days of life to 6 months, slows down 6-12 months Involution phase from 12 months to age 3-6 years 1/3 present at birth as light port wine stain

Answer 993

Active nonintervention for uncomplicated hemangiomas that are not disfiguring: regular monitoring and attention to psychosocial effects Intervention for lesions at increased risk for complications, scarring, disfigurement Periorbital - refer to opththalmology, **oral propranolol 0.5 - 1mg/kg/day then gradually increase to target 2mg/kg/day** Refer to pediatric derm, vascular anomalies team etc. if tx **Oral propranolol** in addition to meticulous wound care and appropriate analgesia for the tx of ulcerate hemangiomas that may cause permanent disfigurement, interfere w/ daily activities, or do not response to wound care measures Uncommonly used tx: vincristine, interferon alpha, injected corticosteroids, laser therapy

Answer 994

disorder of dermal capillaries and post capillary venules Occassionally assoc w/ other congenital or genetic syndromes (Sturge-Weber, or AV malformation syndrome) Present at birth BLANCHABLE from red/dark pink, grows proportionally w/ child Will darken and often become nodular as child grows, will not regress Lesions onf ace tend to follow branches of trigeminal nerve

Answer 995

Pulse dye laser therapy - standard, lightens lesion byt does not remove Referrals: Ophthalmology if eyelids involved d/t association w/ glaucoma Neurology if facial lesions assoc. w/ seizures

Answer 996

Diffuse melanocytes within dermis, d/t interrupted movement during fetal development Non-tender, blue-black-gray macular, usually lower back and buttocks **Mgmt** Lighten over time and often disappear during childhood No tx required No malignancy potential

Answer 997

Retention of keratin and sebaceous material Raised white bumps, mainly on nose and cheeks **Mgmt:** No tx Resolve spontaneously within a few weeks Parent/caregiver eassurance most important intervention Do not pick at lesions as may cause scarring

Answer 998

Unknown etiology, thought to be immaturity of pilosebaceous glands Occassionally present at birth, usually appears within first 48 hours and resolves by day 5-7 Erythematous papules that progress to pustular **Mgmt:** Observation, no tx necessary Resolves spontaneously, reassure parents 30-70% of infants will experience these lesions

Answer 999

Impaired epidermal layer, w/ impaired barrier allowing irritants into dermis Decreased water content d/t poor barriers Itch-scratch cycle worsend condition Believed to have genetic component 11% of children in the US - 60% first year of life - 85% by age 5 - 40% resolves by early adulthood Birth to 2 years: Red, crusty, extensor, face, scalp 2-12 years: Lichenification of flexure surfaces \> 12 years: similar to child but common on hands and feet

Answer 1000

3 prongs: Eliminate triggers Hydrate - thick creams/ointments. Avoid lotions Control itch - sedating antihistamines, topical corticosteroids to control flares

Answer 1001

Results from stimulation of sebaceous glands by maternal/infant adrogens Present: face, forehead, nose, cheeks Acneiform lesions starting in the first month of life, usually lasts 1-2 months Affects 20% of infants **Mgmt:** Self-resolving Advise pts/caregive not to pick at lesions Benzoyl peroxide 2.5% applied to region once a day is acceptable

Answer 1002

Ineffective defection, manifested by straining in the absence of constipation Funtional disorder defined as at least 10 minutes of straining/crying before successful passage of soft stool in an otherwise healthy infant Can occur up to 9 months of age Resolves spontaneously as infant matures Reassure parents

Answer 1003

Usually in areas of dense sebaceous glands (scalp, face, groin, underarms) Thought to be overstimulation of sebum production Possibly lipid-dependent yeast Erythematous plaque, appears greasy w/ yellow scales Commonly seen in infants but can be present through life **Mgmt:** Apply emollient (petrolatum, vegetable/mineral oil) overnight, then remove plaque w/ soft brush For other parts of nody: Ketoconazole 2% cream once daily x 1 week or low-dose hydrocortisone 1% daily x 1 week

Answer 1004

Genetic disorder resulting in hyperkeratinization of hair follicles Rough skin texture, gooseflesh appearance/chicken skin Usually asymptomatic, occassional pruritus Worst w/ cold, dry weather **Mgmt** No cure/universally effective tx available Regular skin care regimen w/ lotions and creams can lead to improvement Use mild soap/cleansers, lubricate w/ moisturizer Lactic acid lotions, salicylic acid, alpha-hydroxy acid lotion, topical steroid, retinoid acid

Answer 1005

Dyspnea HF sx Syncope Note: when syncope is d/t cardiac, it it d/t bradycardia and/or obstruction

Answer 1006

**95% reported sx weeks prior to event:** **Unusual fatigue (70%)**, sleep disturbance (48%), SOB (42%) Indigestion (39%), Anxiety (35%) **Sx of women during ACS:** SOB (58%) Weakness (55%) Unusualy fatigue (43%) Dipahoresis (39%) Dizziness (39%) Chest pain/pressure (30%) No chest discomfort (43%)

Answer 1007

Clinical presentation =\> 75 years: Dyspnea, Neurological sx (syncope, weakness, acute confusion), Chest pain/prssure Be liberal in the EKG in the elder

Answer 1008

**S1** Beginning of systole Closure of MITRAL and TRICUSPID **_LUB_**-dub **S2** End of systole Closure of AORTIC and PULMONIC lub-**_DUB_** **"MTAP"** Both heard best w/ diaphragm

Answer 1009

Benign, document, no f/u needed Widening of normal interval between aortic and pulmonic valves Caused by delay of pulmonic component Heard best pulmonic region Split INcreases on patient INspiration Found in the majority of adults

Answer 1010

Atrial Septal Defect

Answer 1011

Fixed split, no change w/ inspiration Paradoxical split - narrows or closes w/ inspiration Heard best in pulmonic region Fixed split often found in uncorrected septal defect Paradoxical split often found in conditions that delay aortic closure such as LBBB Resolve w/ tx of underlying condition

Answer 1012

Marker of ventricular overload and/or systolic dysfunction Heard best in early diastole, can sound like it is "hooked on" to the back of S2 LOW pitch, best heard w/ bell For dx of HF, correlated w/ sx such as dyspnea, tachycardia, crackles Can resolve w/ tx of underlying condition May not be heard if pt is euvolemic

Answer 1013

Marker of poor diastolic function, most often found in poorly controlled HTN or recurrent MI Heard late in diastole, sounds like it is "hooked on" to front of S1 Sometimes called a "pre-sysolic" sound Soft, low-pitch but higher pitch than S3 Best heared w/ BELL of steth Can resolve w/ tx of underlying condition

Answer 1014

I - very faint, may not be auscultated unless thin chest wall and ideal circumstances - typically no clinical consequence II - Quiet but immediatley heard III - Moderately loud w/o thrill - as loud as S1 and S2 IV - Loud w/ thrill V - Very loud w/ Thrill VI - Audible w/o stethoscope

Answer 1015

**Harsh** - heard well w/ both bell/diaphragm, aortic stenosis **Rumble** - LOW, heard best w/ bell, mitral stenosis **Blowing** - HIGH, heard best/ diaphragm, aortic regurgitation **Musical** - vibratory quality - Still murmur

Answer 1016

Likely benign **Consider benign if all noted:** Negative hx Lower grade (Grade III or lower) No radiation S1 S2 intact No heave/thrill PMI WNL Softens or disappears w/ supine to stand

Answer 1017

Consider pathologic (order echocardiogram) until proven otherwise if =\> 1 of the following present: Abnormal Hx Higher grade \> Grade III Radiation S1 S2 obliterated w/ Thrill or heave PMI displaced Increases w/ intensity w/ supine to stand

Answer 1018

Carotid bruit: usually softer, often unilateral, differtn sound than that of chest Radiating murmur: louder, bilateral, same sound and timing as found in chest

Answer 1019

**CVD 56%** - hypertrophic cardiomyopathy most commonly implicated, 1/3 of all deaths **Blunt trauma causing structural changes to heart 22% -** eg. cardiac concusion, likely induces VF, baseball, basketball most commonly associated **Commotio cordis 4% -** likkely underreported, a chest blow that interrupts cardiac rhythm WITHOUT visible cardiac injury **Heat stroke 2%** - likely d/t HYPERKALEMIA induced by extensive tissue damage

Answer 1020

NSAID Corticosteroid use Cigarette smoking

Answer 1021

High pitched Diastolic murmur heard best at R side of sternum 2nd ICS

Answer 1022

FEMALES: 0.6 - 1.1 MALES: 0.7 - 1.3

Answer 1023

Kiwi Bananas Avocadoes

Answer 1024

Lyrica FDA approved for pain reduction in fibromyalgia

Answer 1025

Pain relief Controlling endometrial patch growth Preserving fertility Tx options: Hormonal contraception, Provera tabs PO, NSAIDs

Answer 1026

Inflammation of the eyelids **Mgmt:** Good lid hygiene mainstay Warm compresses Lid massage Lid washing - very dilute baby shampoo Avoid vigorous washing Topical azithromycin 1% ophthalmic up to 4x/a day x 4 weeks an option to minimize bacterial overgrowth, may relieve s/sx. Ointment can blur vision after application Oral abx in severe cases - tetracyclines, azithro Doxy 100 mg daily x 2-4 weeks Z-pak

Answer 1027

Infertility in 10-30% of pts after first episode of PID Increased risk of ectopic pregnancy d/t scarred fallopian tubes Fitz-Hugh-Curtis syndrome occurs in 5-30% of cases of pelvic infection (perihepatitis - severe RUQ abd pain pleuritic, might refer to right shoulder)

Answer 1028

Elevated total cholesterol and TG

Answer 1029

Elevated TG Elevated HDL Elevated LDL

Answer 1030

Elevated total cholesterol Elevated TG Elevated LDL

Answer 1031

Inflammatory disease that is most common cause of ACQUIRED heart diseae in children Usually affects aortic and mitral valves Associated w/ strep infection Collagen disease that injures heart, blood vessels, joints, and subcutaneous tissue

Answer 1032

Orthostatic hypotension Yellowing of skin Brittle nails Pruritus Halitosis Decreased temp Bradycardia Arrhythmia

Answer 1033

Spironolactone to decrease/control hirsutism Low-dose OCP to suppress ovaries Provera tablets to induce menses Glucophage to induce ovulation if pregnancy desired

Answer 1034

LLQ pain after eating Depressed owel sounds (increased if obstruction) Tender, firm, palpable mass in left iliac fossa tender rectum hemorrhoids

Answer 1035

Most frequent observed in patients w/ decreased left ventricular distensibility Common in hypertensive heart disease, aortic stenosis, hypertrophic cardiomyopathy LVH - present in all these conditions

Answer 1036

Occurs in high-output states such as thyrotoxicosis or pregnancy Almost always present in patients w/ hemodynamically significant chronic mitral regurgitation S3 gallop - important and early finding of HF assoc w/ dilated cardiomyopathy and may also be heard in pts w/ diastolic HF (S3 being heard in systolic HF more common)

Answer 1037

Dopamine agonist used in PD

Answer 1038

Corticosteroid tx Eye inflammation/trauma Neoplasm Neovascularization Increasing age

Answer 1039

Rye Palmetto Pumpkin pending further studies considered emerging tx by the AUA

Answer 1040

lingering cold Nasal sx are usually resolved Cough worsens because pathogen attached to respiratory cilia and produced toxins that paralyze cilia and induce inflammation of respiratory tract

Answer 1041

Mild hearing loss: 26-40 dB Moderate hearing loss: 41-55 dB Profound hearing loss: \> 91 dB

Answer 1042

Hysterosonogram Procedure - uterus is filled w/ saline and transvaginal pelvic U/S is performed

Answer 1043

female gender Obesity HL rapid weight loss (e.g. in bariatric sx) age \> 50 years pregnancy genetic fx diet w/ high glycemic index

Answer 1044

**Do not use in OS** May weaken quadriceps tendon May produce cutaneous thinnking May produce depigmentation

Answer 1045

Disease of widespread vascular endothelial malfunction and vasospasm that develops after 20th week of pregnancy up to 4-6 weeks postpartum

Answer 1046

Age \> 40 First pregnancy Pregestational DM High BMI Primary HTN Renal Disease Family Hx Multiple gestation African ancestry Emerging risk fx: Vit D Def, Maternal periodontal disease

Answer 1047

Elevated **BP \> 140/90** or w/ preexisting HTN, if **SBP increased by 30 mmHg or DBP by 15mmHg** Must be on successive measurements 4-6 hours apart _within 1 week_ Proteinuria **\> 300 mg/24 h or 1+ on 2 random urines** at least 6 hours apart _within 1 week_ Sudden increase in edema or onset of facial **edema** suggestive of preeclampsia but not required for dx

Answer 1048

Prompt recognition Rest Maternal and fetal monitoring Anti-HTN meds w/ \> 160/110 (either) Anticonvulsant meds including Mg Birth

Answer 1049

**Mom:** GA 37 weeks or \> Uncontrollable BP Platelet count Suspected abruption, ruptured membrane Pulmonary edema SOB or CP w/ O2 sat \> 94% on RA Deteriorating hepatic/renal function Persistent h/a, vision change, epigastric pain, N&V **Baby:** Severe growth restriction Non-reassurign fetal test results Oligohydramnios

Answer 1050

Coos in response to voice

Answer 1051

Imitates sounds, nonspecific mama, papa

Answer 1052

Specific mama, papa, 2-3 syllable words imitated

Answer 1053

4-7 words, jargon,

Answer 1054

Extensive jargon, 20-25% of speech understood by strangers

Answer 1055

20 words, 50% speech understood by strangers

Answer 1056

\> 50 words, 2-word phrases, less jargon, 60-70% of speech understood by strangers

Answer 1057

400 or \> words 2-3 word phrases, uses pronouns 75% speech understood by strangers

Answer 1058

3-6 word sentences asks questions, tells stories Nearly all speech understood by strangers

Answer 1059

6-8 word sentences Names 4 colors Counts 10 objects correctly

Answer 1060

Moves all extremities Reacts to sound by blinking/turning Well-developed sense of **smell** Preference for **higher pitched voices** Reflexes: tonic neck, palmar grasp, babinski, rooting, suck Able to be calmed by feeding, cuddling Responds to cries of other neonates Reinforces presence of developmental tasks seen in exam room

Answer 1061

**Lifts head** Hold head erect **Follows objects through visual field** Moro reflex fading **Spontaneous smile** Recognizes parents

Answer 1062

**Reaches for objects** Brings objects ot mouth Raspberry sounds Sits w/ support Rolls back to sdie **Laughs** Recognizes food by sight

Answer 1063

**Sits briefly w/o support** Scoops small object w/ rake grip, some thumb use **Hand to hand transfer** Recognizes "no"

Answer 1064

Stands alone **Imitates peek-a-boo** Picks up small object w/ thumb and index finger **Cruises** Follows simple commands such as "Come here"

Answer 1065

**Walks solo** Neat pincher grasp Place cube in cup **Tower of 2 bricks** **Scribbles** spontaneously Indicates wants by pointing Hands over objects on request

Answer 1066

**Points to several body parts** Uses spoon w/ little spilling **Walks up and down steps** w/ help Understands 2-step commands Feeds self Seats self in chair Carries and hugs doll

Answer 1067

**Kicks ball upon request** **Jumps w/ both feet** Developing handedness Copies vertical and horizontal line Washes and dries hands **Parallel play**

Answer 1068

Walks backwards **Hops on one foot** Copies **circle** **Gives first and last name**

Answer 1069

Holds crayons w/ fingers **Walks down stairs w/ alternating steps** Rides **tricycle** Copies circles Dresses w/ supervision

Answer 1070

Responds to command to place object in, on, or under table Draws circle when one is shown Takes off jacket and shoes Washes and dries face **Cooperative play** Knows gender

Answer 1071

Runs and turns w/ balance Stands on 1 foot for at least 10 sec Counts to 4 **Draws person w/o torso** **Copies +** by imitation **Buttons clothes** Dresses self except tying shoes Can play w/o adult input for about 30 min Verbalizes activities to do when cold, hungry, tired

Answer 1072

**Catches ball** Knows age Knows right/left hand **draws person w/ 6-8 body parts including torso** Able to complete simple chores sense of gender **identifies best friend** Likes teacher

Answer 1073

**copies triangle** draws person w/ at least 12 parts **Prints name** reads multiple single syllable words counts to 30 or beyond **Ties shoes laces** generally plays well w/ peers no significant behavioral problems in school Names intended career

Answer 1074

**copies a diamond** **Able to read simple sentences** Draws a person w/ at least 16 parts Ties shoes Knows day of the week

Answer 1075

able to add, subtact, borrow, carry Understands concept of working as a team able to give response to question such as what to do if an object is accidentally broken

Answer 1076

Lead poisoning

Answer 1077

Lead-based paint, found in majority of homes built before 1957 if not deleaded Banned since 1978 - lead paint use Risk increases if lead-based painted home is undergoing renovation

Answer 1078

Young child living in/frequently visiting a home w/ lead-based paint/built before 1957, undergoing renovation Less common is a young child w/ an adult whose hobby/work involves lead exposure or who lives near industrial area where lead release is likely

Answer 1079

2-3 years if lead-based paint is source all children 6 years and All ages at risk for non-paint source Plumbism from pain source uncommon in \> 4 years unless developmental disability or pica present Additional household Pb sources: unregulated toys, inexpensive jewelry

Answer 1080

Folk remedies (up to 30%) Great and Azarcon (aka alarcon, coral, luiga, maria luisa, rueda) are traditional remedies used in Latino communities to tx upset stomach. Fine orange powders w/ lead content as high as 90% Ghasard, Indian folk remedy used as tonic Ba-baw-san Chinese folk remedy used to tx colic Candies produced in Mexico may contain lead Lead-based products used in stained glass and bullet making

Answer 1081

focus on child 6 years and Test at risk housing for lead-based paint If de-leading is moving not an option: keep child away from peeling paint or chewable surfaces, create barriers between living/play areas and lead sources, regularly wash children's hands and toys to remove paint dust, regularly wet-mop floors and wet-wipe window components to keep paint dust contained, prevent children from playing in bare soil, if possible provide sandboxes, soil around foundation of a building painted w/ lead based pain often contains high levels of lead

Answer 1082

Few manifestations, if any Environmental hx is critical to identify children at risk Severe: anorexia, constipation, recurrent abd pain

Answer 1083

First line: remove Pb hazard Chelation tx for higher levels - mainstay for blood levels \> 45 ug/dL Expert in mgmt of lead chemotherapy should be consulted prior to use of chelation agents **Tx per blood level:** If 10-14 - Repeat and confirm within 1 month, avoid exposure, repeat testing in 3 months 15-19 - Repeat and confirm within 1 month, avoid exposure, repeat testing in 2 months 20-44 - Repeat to confirm within 1 week, aggressive hazard mgmt, environmental assessment by local health dept, intervention to reduce exposure **45-69 - Repeat to confirm within 2 days,** aggressive environmental intervention to reduce exposure, _chelation tx_ **\>69 - Medical emergency, r**epeat testing immediately to confirm, begin chelation tx, hospitalize patient, w/ care by experts in plumbism

Answer 1084

**BMI - age and gender specific** Overweight \> 95th percentile Risk of overweight 85-95th percentile Underweight **Indicators of nutritional status:** HC for age 95th percetile HC reflects brain size, often used to screen for potential developmental problems from birth to 24 months **Length or short stature for age** consider familial short stature Stunted growth d/t long-term malnutrition, delayed maturation, chronic illness, genetic disorder **Underweight for length** Recent or chronic malnutrition, dehydration, genetic disorder

Answer 1085

Fetal weight less than 10th percentile for GA Typical initial finding: uterine size less than anticipated for GA

Answer 1086

Infant weight

Answer 1087

Low Apgar Meconium aspiration Hypoglycemia Poor body temp regulation Polycythemia Intrauterine asphyxia

Answer 1088

Any condition that can lead to decreased uterine and placental blood flow: stress, HTN, smoking, use of vasoconstrictors such as cocaine, meth, advanced DM w/ vascular disease, kidney disease Any condition that can lead to decreased oxygen carrying capability: poorly controlled asthma or other pulmonary disease, smoking, profound anemia, heart disease Other fx: insufficient prenatal, malnutrition of poor weight gain, chronic infection, placenta previa

Answer 1089

Chromosomal defects Multiparity

Answer 1090

Confirm condition Continue to monitor w/ serial U/S and appropriate testing of fetal well-being (kick count, non-stress test, biophysical profile

Answer 1091

Birth weight \> 90th percentile for GA after correcting for neonatal sex and ethnicity Typical initial finding - uterine size \> anticipated GA though of limited accuracy U/S eval positive predictive value of 30-44%

Answer 1092

Most commonly: shoulder dystocia Perinatal asphyxia Respiratory distress syndrome In cases of poorly controlled maternal DM, additional fetal or neonal risks (e.g. hypoglycemia)

Answer 1093

Maternal DM w/ poor glycemic control Glucose intolerance Excessive maternal prepregnancy weight/stature Excessive weight gain during pregnancy Previous hx of macrosomic infant Postdate gestation

Answer 1094

Multiparity Male fetus

Answer 1095

Tight glycemic control Elective caesarean delivery (not supported in literture, though possibly indicated if fetal weight \> 4,500 g, hx of cesarean delivery and/or shoulder distocia)

Answer 1096

60% at age 20-30 to 53% at age 60-80

Answer 1097

=\>20% reduction

Answer 1098

Increased body fat 38-45% in women 36-38% in men Decreased serum albumin (avg 3.8g/dL from 4.7g/dL avg at 20-30y) 80% of relative kidney weight 55-60% relative hepatic blood flow

Answer 1099

Half life of 1.5 to 9 hours Cmax 15-100 min Minimum first pass effect CYP450 1A2 substrate - CYP450 isoenzyme levels can drop by up to 30% in elders by age 70 - CYP450 1A2 activity influence by estrogen in women

Answer 1100

Avoid drugs w/ systemic anticholinergic effect Risk of confusion, urinary retention, constipation, visual disturbance, hypotension If unavoidable, choose product w/ least amount of this effect

Answer 1101

1st generation antihistamines (Chlorpherniramine, Diphenhydramine, Hydoxizine, Cyproheptadine, Promethazine) - clearance reduced w/ advanced age, tolerance develops if these products are used as a hypnotic Doxepin (Sinequan, Silenor) - sleep aid - avoid in elderly

Answer 1102

Desired effect for OAB Oxybutynin (Ditropan) - sustained release better tolerated w/ similar therapeutic efficacy

Answer 1103

Amitriptyline is prodrug of nortriptyline Nortriptyline is a metabolite of Amitriptyline **Nortriptyline has 50% less anticholinergic effect**

Answer 1104

Dry as a bone (dry mouth) Red as a beet (flushing) Mad as a hatter (confusion) Hot as a hare (hyperthermia) Can't see (vision changes) Can't pee (urinary retention) Can't spit (dry mouth) Can't shit (constipation)

Answer 1105

**Avoid** as first line tx of A-Fib **Rate control yields better balance** of benefits and harms than rhythm control in older adults **Amiodarone** is assoc. w/ multiple toxicities including thyroid dx, pulmonary disorders, and QT prolongation Irreversible pulmonary fibrosis long QT = sudden cardiac death risk V-Fib, V-Tach

Answer 1106

Topical low-dose intravaginal estrogen acceptable to tx dyspareunia, lower UTI, vaginal sx in elderly Typically do not tx asymptomatic bacteriuria in elderly low estrogen dose okay to use w/o progestin opposition in elderly

Answer 1107

Lack of evidence of benefit vs risk at age 80 or \> Use w/ caution

Answer 1108

Greater risk of bleeding than w/ Warfarin in adults 75 years and \> Lack of evidence for efficacy and safety in pts with Cr Cl \> 30 mL/min (0.5 mL/s)

Answer 1109

50% rate of use Increase over time and w/ advancing age e.g. Ginkgo, ginseng, garlic - the 3 Gs w/ antiplatelet effect, problematic w/ prescription antiplatelet meds

Answer 1110

Ginkgo biloba Garlic Ginseng 3 G's

Answer 1111

CYP450 3A4 inducer Potential for serotonin syndrome when taken w/ SSRI

Answer 1112

GABA agonist Sedating Not to be used w/ benzo, ETOH, sedative-hypnotics

Answer 1113

similar effect to benzo hepatotoxicity potential

Answer 1114

May have **immune stimulating effects** Evidence does not support efficacy in treating or preventing common cold **Not to be recommended** However, appears **relatively safe,** although GI side effects and allergic reactions have been reported May interfere w/ immunosuppressant tx

Answer 1115

Large high quality studies have not shown saw plametto to be effective in tx of BPH Do not recommend Appears well-tolerated, rare serious side effects

Answer 1116

Hyper acid secretion syndrome

Answer 1117

Rebound hypersecretion in 60-90% using PPIs for more than 2 months Explains increaed GI sx w/ discontinuation Consider tapering medication w/ reducing dose, followed by QOD use, H2RA, antacid use w/ sx Potential decrease in absorption of select micronutrients such as Iron, B12 Supplementation needs not established Increased fx risk - calcium supplement - choose Calcium citrate as absorption is less affected by gastric acidity Decreased magnesium absorption - increased risk w/ Mg depleting med like Thiazides/Loop diuretics, Digoxin toxicity risk increased w/ low Mg

Answer 1118

Inhibit acid secretion by blocking histamine H2 receptors on the parietal cell Examples: cimetidine, ranitidine, famotidine, nizatidine Achieve less acid suppression than PPIs

Answer 1119

Muscle cramps, heart palpitations, dizziness, tremors, seizures Preferred dx: 24 hour urine Mg (Serum Mg very poor reflection of Mg status)

Answer 1120

Elemental Mg (lactate or gluconate preferred) 200-400 mg daily lower dose recommended in renal impairment

Answer 1121

CYP450 2C19 inhibition by PPI = 20-40% decrease in antiplatelet effect **recommend: separate by 12-20 hours**

Answer 1122

Decreased therapeutic effect Beta 2 agonists such as albuterol Beta antagonists such as metropolol, carvedilol d/t decrease in beta receptors in aging (lungs and heart)

Answer 1123

Add to bronchodilator in elderly less age-related impact e.g. tiotropium, ipratropium bromide

Answer 1124

Dihydropyridines (DPH) such as Amlodipine = most powerful BP reduction regardless of race, preferred Non-DPH such as verapamil and diltiazem = increased sensitivity to PR-prolonging effects in the elder, blunts HR,

Answer 1125

If Cr Cl \> 50 mg/dL - standard dosing for tx of UTI If Cr Cl Decreased concentration of abx in urinary tract

Answer 1126

If Cr Cl =\> 30 mL/min = no change in dose = 250-750 BID If Cr Cl

Answer 1127

Cr Cl \> 30 ml/min = no change 1 DS tab BID Cr Cl 15-20 ml/min = 1 DS tab every 24 hr or 1 SS tab every 12 hours Cr Cl

Answer 1128

Likely effective against ESBL producing strains, most often K. pneumo, E. coli, Acinetobacter Half life increases to 50 hours in renal impairment

Answer 1129

Cr Cl approximates GFR but might overestimate d/t creatinine secreted by proximal tubule, filtered by the glomerulus

Answer 1130

150 mL/min

Answer 1131

Stage II-III CKD

Answer 1132

Muscular bulk = increased d/t muscle metab Malnutrition, muscle wasting, amputation = reduced d/t reduced muscle mass and/or reduced protein intake Vegetarian diet = decrease in creatinine generation Ingestion of cooked meats = transient increase in creatinine generation, might be blunted w/ transient increase in GFR Older age = reduction in creatinine generation, age-related decline in muscle mass Female sex = reduced d/t reduced muscle mass Obesity = no change, excess mass is fat

Answer 1133

Extremes of age and body size Severe malnutrition/obesity Disease of skeletal muscle Paraplegia/quadriplegia Vegetarian diet Rapidly changing kidney function Pregnancy

Answer 1134

Decreased renal blood flow d/t reduction in CO = Less reserve, increased risk of drug-induced nephrotoxicity

Answer 1135

Assure adequate hydration Take ACEI dose in the morning to allow for overnight excretion of renal potassium to avoid hyperkalemia

Answer 1136

Increased risk for syncope, bradycardia, pacemaker insertion, hip fx Weigh against the drug's generally modest benefits in AD

Answer 1137

Increased risk of death w/ SGA

Answer 1138

If \> 40 mg (in all ages) = QT prolongation effect w/ no additional benefit Max dose of 20 mg/daily in elderly Contraindicated in: congenital long QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute MI, or uncompensated HF, other drugs that prolong QT Max dose of 20 mg/daily in: age \> 60y, hepatic impairment, concomitant cimetidine, many PPIs

Answer 1139

In pts found to have persistent QTc measurements \> 500 ms Discontinue Citalopram

Answer 1140

all extended release products are released in the jejunum Decreased pH in the elder, reduced ability to dissolve the enteric coating Avoid!

Answer 1141

Do not take within 2 hours of each other d/t chelation effect

Answer 1142

expression of psychological stress through physical sx somatoform disorders demonstrate mind-body interactions that cause real distress to pt Eg. hypochondriasis, pain disorder, coversion disorder

Answer 1143

Lyme carditis Lyme meningitis Facial nerve paralysis Lyme encephalitis Lyme arthritis

Answer 1144

Grapefruit and other citrus fruits are known to inhibit Allegra and reduce effectiveness

Answer 1145

Amoxicillin 250-500 mg TID x 10-21d (for pregnant, lactation, and

Answer 1146

Used to test for color blindness

Answer 1147

Systemic steroids

Answer 1148

every 6 months New lesions frequently occur Development of skin ca can occur

Answer 1149

every 3 months until 2 years of age then every 6 months until age 5 then yearly

Answer 1150

\> 0.9 normal 0. 6-0.8 moderate 0. 5 and

Answer 1151

10-35 iu/L

Answer 1152

Hep B Order Hep B surface antigen

Answer 1153

Acute viral illness causing fever, ulcerative mouth lesions, cough, coryza, and pharyngitis Seen more frequent in temperate climates (summer and fall) Fever may be as high as 106F Malaise, headache, backache, anorexia, drooling, vomiting, diarrhea Supportive Tx Resolution typically within 7 days

Answer 1154

Dx for scoliosis Child bends forward w/ head and hands down Assess rib hump or prominence

Answer 1155

German measles Stay home from school for 7 days after onset of rash Supportive tx Rest and fluids

Answer 1156

Rash and sx appear within a day or two of infection Scarlet fever produces flushed face, pinpoint red papules w/ a sandpaper-like rash Sx: sore throat, h/a, strawberry tongue

Answer 1157

Cigarette smoking

Answer 1158

Calcium Can occur in two forms: Calcium oxalate or calcium phosphate

Answer 1159

SOB that occurs at night, characterized by sudden awakening after few hours of sleep, w/ feeling of anxiety, breathlessness, and suffocation

Answer 1160

Infants Previous severe exacerbations 2 or more hospitalizations in the past year 3 or more ER visits in the past year hospital/ER in the last month Poort patient perception of sx Lack of written asthma care plan Sensitivity to Alternaria Low socioeconomic status Illicit drug use Major psychosocial problems Comorbidities (CV, COPD) Major psychological disease

Answer 1161

\> 5 nodules or Total inflammatory lesion count \> 50 Total lesion count \> 125

Answer 1162

20-100 comedones or 15-50 inflammatory lesions or total lesion count 30-125

Answer 1163

Fewer than 15 inflammatory lesions or Total lesion count

Answer 1164

**Abdominal CT** provides diagnostic view of inflamed pancreas Abd U/S can dx gallbladder disease but does not help with pancreatitis d/t limited view of the organ **If Amylase and Lipase are 3x the upper limit of normal** and gut perf/infarct have been ruled out, these lab values are diagnostic for pancreatitis **Concurrently order lipase w/ amylase** as amylase can e elevated in other conditions such as perforated duodenal ulcer and other abdominal emergencies, lipase will increase dx specificity for pancreatitis

Answer 1165

**MRI** **MRI** is more accurate in the s_econd or third trimester of pregnancy_ than Duplex U/S because the _gravid uterus alters venous flow characteristics_

Answer 1166

3-6 months If \> 1 episode, lifelong

Answer 1167

Caffeine Butalbital Acetaminophen **- Inexpensive and generally well-tolerated h/a tx** Helps relieve migraine and tesion-type headache pain

Answer 1168

SSRI (sertraline, venlafaxine) to treat arousal sx and associated depression

Answer 1169

hips, wrist, vertebrae

Answer 1170

Disengagement theory Activity theory Continuity theory

Answer 1171

Antacids are most effecive when used _1-3 hours after meals and at bedtime_ Antacids neutralize that secreted acids and inactivate pepsin and bile salts Interact w/ many other medications, should be used at least 2 hours apart Fluroquinolones - antacid shoudl be used **2-4 hours before** or **4-6 hours after** the fluoroquinolone

Answer 1172

1 = No restriction 2 = Generally can use 3 = Generally do not use 4 = Do not use

Answer 1173

No sx of pregnancy AND No intercourse since start of last menses Correctly and considently using a reliable method of contraception Within 4 weeks postpartum Fully or nearly fully breastfeeding (\>85% of needs), amenorrheic, and

Answer 1174

**Sunday start** - start COC/patch/ring on Sunday after menses begin - so that menses occur during week not weekend if using hormone-free week monthly, back up for 7 days needed **First day of menses start -** No back up needed **Quick start** - not pregnant, start COC/patch/ring that day, back up for 7 days **Jump start -** unprotected intercourse since LMP, prescribe ECP, start COc, patch, ring that day, use back up for 7 days

Answer 1175

Do not interact, but abx reduces gut flora continue OCP Use back up for duration of abx + 7 days

Answer 1176

1 = no restriction

Answer 1177

1 = no restriction SBP

Answer 1178

OCP failure - spotting ocurs while on abx, woman thinks its her period and stop taking the pill! Teach: Continue to take OCP even if spotting occurs Use backup method for duration of time taking the interacting medication + 7 days

Answer 1179

Category 3 Exercise caution Gastric bypass = duodenum gets bypassed = decreased OCP absorption

Answer 1180

COC is NOT acceptable the first 3 weeks postpartum Post partum is a prothrombotic state May decrease quantity of breastmilk

Answer 1181

Foreign body effect results in sterile inflammatory response that is toxic to sperm and ova impairs implantation Local uterine changes enhances by presence of copper Approved to remain in place for 10 years, likely effective up to 20 years

Answer 1182

Foreign body effect Sterile inflammatory response that is toxic to sperm and ova imapirs implantation Local uterine changes = thickening of cervical mucus d/t progestin, results in physical barrier to prevent sperm from entering Progestin also induces endometrial thinning, discourages implantation Approved for 5 years - Mirena Approved for 3 years = Skyla

Answer 1183

Systemic OCPs interact w/ many anti-seizure medications

Answer 1184

2 = generally can use

Answer 1185

1 = no restrictions

Answer 1186

1 = no restrictions \*Systemic OCPs interact w/ seizure meds so not preferred in pts w/ seizure disorder

Answer 1187

2 = generally can use

Answer 1188

Etonogestrel - Nexplanon/Implanon Provides daily constant release of low dose progestin Effective for at least 3 years Adverse effects: irregular bleeding, can be managed w/ COC use x 3 months, or timed NSAID use x 2 weeks - Naproxen 550 mg BID (anti-prostaglandin)

Answer 1189

7.2% Emergency contraception helps reduce this risk

Answer 1190

Any time unprotected sexual intercourse occurs, including potential method failure (late or missed pills, late for Depo, dislodged/misplaced diaphragm, condom break/slippage, expelled IUD, etc.)

Answer 1191

IUD - Copper Pregnancy rate if used as EC = 0.09% **ECPs:** - Ulipristal acetate (UPA) 30 mg x 1 dose) - Levonorgestrel 1-2 dose (1.5 if 1 dose) Similar effectiveness if within 3 days after unprotected intercourse in many circumstances UPA \> LNG between days 3 and 5 after unprotected intercourse

Answer 1192

Depending on time taken during menstrual cycle, interferes w/ fertilization by: Inhibit or delay ovulation (most likely effect) when given 2d prior to LH surge Once LH begins, levonorgestrel has no impact on ovulation Inhibits tubal transport of egg or sperm Unlikely mechanism of action: has minimal to no alteration to endometrium therefore unlikely to to inhibit implantation of a fertilized egg

Answer 1193

Most common adverse effects: Nausea 14% Vomiting 1% Dose should be repeated if vomiting occurs within 2 hours of taking In 95% or \> of women, _next period would occur within 3 weeks of taking the medication_ _Obtain pregnancy test_ if menses delayed beyond 1 week of anticipated date of onset

Answer 1194

Take dose within 72 h but also effective up to 120 h after intercourse Improved efficacy when taken earlier in this time frame For two tab regimens: take both pills in single dose or 1 pill and then the second pill 12 hours later **Available OTC for purchase by anyone at any age** though some labeling will state not ot be used in women age Health insurance may cover expense

Answer 1195

Progesterone agonist/antagonist, thus direct inhibitory effech of follicular development and ovum release Changes endometrium possibly can alter likelihood of fertilized egg being implanted vs Plan B: Remains effective when administered immediately before obulation and when LH surger begins Give prior LH surge, inhibit 100% of follicular rupture Given after LH increase, follicular rupture fails to occur within 5-6 days in 50% of cases Given at LH peak, inhibits ovulation by 24-48 hours Approved for use up to 5 days (120 hours) post unprotected sex Rx only

Answer 1196

Take 1 tablet as soon as possible w/ or w/o food within 120 hours of unprotected sex/known contraceptive failure If vomiting occurs within 3 hours, consider repeating dose

Answer 1197

Same as contraceptive mechanism action - foreign body effect, sterile inflammatory response toxic to sperm and ova, impairs implantation Advantage: can be left in place for 10 years for highly reliable contraception Contraindication: Active uterine infection

Answer 1198

Issues of lower efficacy in LNG EC option Not noted w/ EC use of copper IUD in obesity

Answer 1199

Time surrounding menopause Onset of beginning of sx and ends w/ cessation of menses Average onset of perimenopause is 40-45 years Occurs earlier in cigarette smokers Lasts an average of 4 years Can range from a few months to 10 years

Answer 1200

Menopause when no period for 12 months Average age of menopause for a woman in North America is 51.3 years

Answer 1201

Menstural irregularity common Ovulation more erratic but pregnancy still possible Hot flashes and sleep problems usually worse week before menses - reported in 65-75% - hormonal shifts are more dramatic Estrogen levels are usually normal at this stage, but FSH is elevated

Answer 1202

LH and FSH increase (anterior lobe of pituitary) in an attempt to induce ovulation Ovaries fail to respond, sometimes leading to heavy, anovulatory menstural bleeding Levels of estrogen forms and androgens are reduced Hot flashes become more frequent/severe in part d/t FSH surge Surgical menopause = more severe sx

Answer 1203

When given during the first 5 years after menopause, reduction of hot flashes 80% to 95% is expected All types/routes of estrogen are effective Even low-doses are often effected Higher doses (1mg oral estradiol) provide relief in 4 weeks Lower dose provide relief in abotu 8-12 weeks Low dose better tolerated w/ less breast tenderness and uterine bleeding Low dose and short duration as possible for sx

Answer 1204

**Endometrial ca risk w/ unopposed estrogen** 5 year use risk of 2%, 10 year use risk of 4% Must take progestin w/ estrogen to minimize this risk unless woman has no uterus **Increased risk of breast ca w/ long term use** Avoid supplemental estrogen in women who has hx or high risk for CVD, breast ca, uterine ca, venous thromboembolic events, active liver disease Compared w/ oral form, transdermal estrogen use is assoc w/ lower thromboembolic risk in short-term studies

Answer 1205

Many women who use oral HT continue to have sx the addition of topical estrogen via an estrogen containing vaginal cream/ring/tab can be helpful increasing dose of oral estrogen is seldome helpful, likely increases HT adverse effects Vaginal entroitus remains colonized w/ protective flora when HT is used = lower rates of urogenital atrophy and UTIs in women using this tx, whether systemic or local

Answer 1206

Low-dose antidepressant (SSRI and SSNRI) can reduce frequency and severity of hot flashes by 35% E.g. SNRI - Venlafaxine (Effexor) SSRI - Sertraline (Zoloft), Paroxetine (Paxil) Typically in lower dose for vasomotor sx than for dose use for depression Adverse effects: sexual dysfunction including anorgasmia **Gabapentin** has also demonstrated efficacy in reducing vasomotor sx Others: Methyldopa (aldomet), Clonidine (Catapres)

Answer 1207

low-dose OCP can be helpful for sx relief and cycle regulation OCPs contain 3-4x estrogen dose compared to usual dose HT

Answer 1208

Androgen supplementation in the form of low-dose testosterone can be helpful in women w/ low libido postmenopause, and in women w/ continue hot flashes despite HT - particularly problematic in younger women who has undergone surgical menopause Adverse effects: acne, hirsutism, alopecia, vocal changes, clitoral enlargement

Answer 1209

Unexplained vaginal bleeding Acute liver diseae Chronic impaired liver function Thrombotic disease Neuro-ophthalmologic vascular disease Endometrial ca (short-term might be aceptable) Breast ca (short-term might be acdeptable)

Answer 1210

Seizure disorder (d/t potential drug-drug interaction) Dyslipidemia - particularly hypertrigyceridemia (transdermal, intravaginal HT has limited lipid impact)

Answer 1211

When taken w/ calcium supplements, post menopausal HT can help reduce risk of postmenopausal fx by 50% Minimizes further bone loss HT should not be used for this purpose solely, however, other medications available

Answer 1212

Few high quality studies support (e.g. phytoestrogens from apples/carrots/coffee/potatoes etc) OTC topical creams of wild yam, phytoprogesterone etc.; However, w/ poor bioavailability

Answer 1213

Spicy foods, chocolate ETOH Elevated ambient temp/humidity Tight, restrictive clothing Cigarette smoking Hot baths/showers Not relaxed state

Answer 1214

Piriformis muscle irritates the transversing sciatic nerve Causing pain, tingling, and numbness in the buttock and leg Can mimic sciatica Stretching can reduce pain

Answer 1215

Meniscus Tear Positive = audible click is felt over meniscus as knee is brought from full flexion to 90 degree flexion

Answer 1216

**Sine qua non:** Sharp heel pain w/ the first couple of steps in the morning Palpation over medial tubercle of calcaneus usually reproduces pain **Other provocative measures:** Passive dorsiflexion of toes (windlass test) Have pt stand on tiptoes and toe walk

Answer 1217

DeQuervain's Tenosynovitis Patient flexes thumb across palm and the clinician applies ulnar deviation to the wrist reproducing pain

Answer 1218

It is performed by having the patient place a straight arm in about 90 degrees of abduction and 30 degrees of forward flexion, and then internally rotating the arm completely (ie, thumb pointing down) Patient then resists the clinician's attempts to depress the arm. Pain without weakness is consistent with tendinopathy, while pain with weakness is consistent with partial or complete tendon tear.

Answer 1219

Biliary cirrhosis

Answer 1220

Uric acid stone occur in people who do not drink enough fluids or who lose too much fluid, eat a high-protein diet, or who have gout

Answer 1221

calcium oxalate stones

Answer 1222

Calcium phosphate stones

Answer 1223

Struvite stones

Answer 1224

Rotator cuff Tests ability to lower arms from a full abducted position + of pt unable to lower arm w/ same coordianted motion as the unaffected arm

Answer 1225

For rotator cuff Passive painful arc Passively flexing glenohumeral joint while preventing shoulder from shrugging Used to assess degree of impingment Degree of rotator cuff tendinopathy is determined by angle which the arc becomes painful

Answer 1226

Foraminal compression test Confirms cervical radiculapathy Position pt w/ neck extended and head rotated apply downward pressure on head + if pain radiates to limb ipsilateral to which head is rotated 93% specific, 30% sensitive in dx acute radiculopathy

Answer 1227

Weak extension of quadriceps Test: squat and rise Knee jerk diminished Pain from posterior upper glute and goes around thigh to front of leg

Answer 1228

Pain lateral side of LE numbness lateral lower leg Weak dorsiflexion of great tow and foot Test: heel walk

Answer 1229

Pain posterior LE all the way down Numbness to calf area/back of leg Weak plantar flexion of great toe and foot Test: walk on toes Ankle jerk reflex diminished

Answer 1230

Left to right shunting Atrial Septal Defect Ventricular Septal Defecet

Answer 1231

Right to Left shunting Transposition of the great arteries Tetralogy of Fallot Tricuspid atresia

Answer 1232

DiGeorge: aortic arch anomalies Down Syndrome: VSD \> ASD Marfan: Aortic regurg, MVP Turner: coarctation, tricuspid aortic valve

Answer 1233

Transposition of the great arteries right to left shunting Cyanotic ECG: RVH X-ray: egg on a string, w/ cardiomegaly and increased pulmonary vascular markings

Answer 1234

**Tetralogy of Fallot** **Four Defects:** Large VSD RVH Overriding aorta Pulmonary stenosis

Answer 1235

50% highest rate in adolescents, infants, males, low-income, rural areas, native american, african american

Answer 1236

h/a, stomach ache, nausea typically subside quickly

Answer 1237

acute onset of vesicular to bullous lesions all over body range from hives to blisters and hemorrhagic lesions Mucosal involvement w/ blisters on conjunctiva, mouth, and genitals also possible Hx of recent abx can precede onset

Answer 1238

Long asymptomatic period, followed by exercise tolerance, then dyspnea at rest Left ventricular failure eventually occurs

Answer 1239

about 3 months

Answer 1240

dried beans whole grains nuts

Answer 1241

h/a caused by impingement of trigeminal nerve Rare before age 35, peaks at age of 60 F \> M Pain lasts a few seconds and only stops when offending activity ceases

Answer 1242

BUN = renal perfusion Creat = actual tubular function Urine volume, osmolality, specific gravity = ability excrete and concentrate flulid

Answer 1243

Anterior epistaxis usually result of localized nasal mucosa dryness/trauma Most episodes managed w/ simple pressure to area superior to the nasal alar cartilage

Answer 1244

knock knees can be seen in children ages 2-4 Corrects w/o tx by the time child reaches 10 years of age

Answer 1245

Normal 150-200 borderline high \> 200 high \> 500 extremely high

Answer 1246

6-28 weeks - every month 28-34 weeks - every 2 weeks 34-41 weeks - every week

Answer 1247

Bradykinesia Rigidity Tremor at rest Masklike facies Loss of postural reflexes Flexed posture

Answer 1248

13-15 = Mild brain injury 9-12 = Moderate brain injury 8 or less = severe brain injury and coma in 90% of pts

Answer 1249

G6PD deficiency Autoimmune hemolysis sickle cell anemia Rh isoimmunization

Answer 1250

SBP \> 160 DBP \> 100

Answer 1251

between 10 and 13 weeks after LMP

Answer 1252

Usually are more pure, uniform sound

Answer 1253

20% Other sx: irritative voiding sx and urinary frequency

Answer 1254

Scoliosis Tx Should be worn 23 hours per day Worn over a T-shirt to minimize skin discomfort/irritation Assess skin for irritation/breakdown often

Answer 1255

14 ## Footnote **Expected teeth can be calculated by subtracting 4 from age of child in months**

Answer 1256

AAP does not recommend changing to a low-iron formula in constipation Typical tx: adding dark corn syrup, nonstarchy vegetables, and more water Juices that are recommended are apple, prune, and pear Avoid rice cereal

Answer 1257

Onset before 20 years or after 50 years of age poor recovery between episodes Family hx of depression Dysthymia preceding episode of depression

Answer 1258

3-5 days Most cases expect reduction of sx in 3-5 days cough might continue for 1-2 weeks

Answer 1259

CN 9 and 10 Glosspharyngeal and Vagus Assoc w/ gag reflex, symmetrical soft palate, uvula, and voice quality

Answer 1260

Small, pellet-like nodes that are movable, cool, nontender, and discrete Range in size up to 3 mm in diameter

Answer 1261

Induration 10 mm or \>

Answer 1262

2 or more node groups on the same side of the diaphragm 5 year survival rate is 90%

Answer 1263

Most common in 15-45 years old persons Incidence is 10-15x more frequent in women Childhood onset is more severe Common in Klinefelter's Incidence is 1 in 1000 whites and 1 in 250 in black age 18-65

Answer 1264

Vitamin C deficiency Common among elderly patients and bedbound Found in fresh fruits/juices Regular smoker risk increases

Answer 1265

generally, the less viscous the vehicle, less absorption ointment, cream \> gel, lotion

Answer 1266

nulliparity smoking earlier menarche longer menstrual periods obesity ETOH stress

Answer 1267

Stage 1 = silent Stage 2 = intermittent claudification Stage 3 = rest ischemia Stage 4 = ulceration/gangrene

Answer 1268

SSRIs like Prozac are more likely to cause lack of appetite and weight LOSS Digestive upsets, constipation, and diarrhea common side effects Insomnia, vivid dreams may also occur

Answer 1269

**Diazepam** Rapid onset of action and relatively sustained effect

Answer 1270

Quinolones and tetracyclines

Answer 1271

Deviation of one or both eyes Latent strabismus occurs only under monocular conditions Manifest strabistmus under binocular conditiosn

Answer 1272

May be itchy, round lesion Appear suddenly Brown w/ waxy apperance and scaly surface

Answer 1273

Underweight: 28-40 lbs Normal weight: 25-35 lbs

Fitzgerald Review FNP Flashcards

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