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Flashcards in Gold Deck (1363):
1

Assessment of optic disc - what cranial nerve?

CN II

2

Symptoms of low CO

Dyspnea w/ exertion

Chest pain

ORTHOPNEA

Syncope or near syncope

3

What murmur: Holosystolic, blowing quality, Grade II-III/VI w/ predictable pattern of radiation (axilla)

Mitral regurgitation

Blood regurgitates back to left atrium = Low CO

4

What is holosystolic murmur

Murmur is heard ALL of systole at same intensity

5

Describe incompetent valve

valve cannot CLOSE properly

6

Pattern of radiation - aortic regurgitation

Radiation to neck/carotid

7

Most common target organ damage in HTN

LVH, MR is common in LVH

8

Asthma flare - assess what first?

FEV1

Oxygen Sat drops LATE in an asthma flare

Asthma is a disease of AIR TRAPPING, difficulty getting air OUT

Oxygen Sat drops when difficult to get air in, which is LATE in asthma flare

At 90% O2 sat, 60 PaO2

9

Describe asthma pathophysiology

Disease of AIR TRAPPING

Disease of airway inflammation w/ superimposed bronchospasm

Inflammation begets bronchospasm

10

Where to auscultate renal arterires

MCL at level of elbow

11

Bruit what is occuring

Turbulent blood flow through at atherosclerotic vessel

12

Grade 1 and 2 hypertensive retinopathy

Visual changes

Findings

Common in poorly-controlled HTN No visual changes w/ low-grade findings

13

Renal bruit

Bruit occassionally noted with renal artery stenosis

Cause of secondary HTN

Usually w/ markedly elevated BP at presentation

14

Evidence Hierarchy

Systematic review (meta-analysis)

RCT

Cohort Study

Case-control

Case series

Case report

Editorial

Expert opinion

15

Primary prevention

Prevent health problem, most cost-effective

Immunizations

Counseling

Disease prevention

16

Secondary prevention

Detecting disease early, asymptomatic/pre-clinical

BP checks, mammography, colonoscopy

17

Tertiary prevention

Minimize negative disease-induced outcomes

Avoid target organ damage

18

Burn prevention - hot water

Set to no hotter than 120F

At 130F 3rd degree burn at 30 seconds exposure

At 140F 3rd degree burn at 6 seconds exposure

19

Diphtheria

Pseudomembrane

Upper airway obstruction (cause of death)

Stridor (sound of upper airway obstruction)

 

20

Herd immunity

95% need to be immunized for herd immunity

Measles - droplet - very contagious

21

Immunization principles

Remove artificial barriers - need only focused history prior to receiving vaccines

Re-immunize when in doubt; risk is minimal

Only defer in the presence of moderate to severe illness (with or without fever)

22

Which immunizations cannot be given?

Neomycin Allergy

IPV

MMR

Varicella

23

Which immunizations cannot be given?

Streptomycin, Polymyxin B allergy

IPV

Vaccinia (smallpox)

24

Which immunizations cannot be given?

Bakers Yeast Allergy

Hepatitis B

25

Which immunizations cannot be given?

Gelatin allergy

MMR

Varicella

26

Which immunizations cannot be given?

Egg Allergy

None

Egg allergy NOT a contraindication to flu vaccine

27

Anaphylaxis Treatment

Patent Airway 

  1. Epinephrine (IM preferred d/t more dependable absorption)
    1. No contraindication to epinephrine use in anaphylaxis
    2. Repeat epinephrine every 5 minutes if symptoms persist or increase
  2. Antihistamine (only use WITH epinephrine)
    1. Benadryl
    2. Ranitidine
  3. Biphasic response: observe for 2 hours in an ER or urgent care

28

Tetanus

C. Tetani

Obligate anaerobe

Grow in the absence of ambient O2

Deep wounds

 

29

Hep B

Why age 19-59 recommendation for previously unvaccinated adults

Not as robust immune response to Hep B vaccine after age 59

30

HPV Type

Genital Warts

6, 11

31

LAIV Vaccine

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

32

LTBI lifetime risk of developing active TB

5-10%

The majority within the first 5 years

33

Hep B Vaccine

Birth

1-2 months

6-18 months

34

RSV vaccine

frequency

Max age final dose

2, 4, 6 months

Max age for final dose 8 months

35

Dtap vaccine

Tdap vaccine

Dtap

2, 4, 6 months

15-18 months

4-6 years

 

(Tdap at 11-12 years)

36

Hib vaccine

ActHIB: 3 doses

2, 4, 6 months

 

PedvaxHIB: 2 doses

2, 4, months

 

Booster at 12-15 months

37

Pneumococcal Vaccine

Prevnar PCV 13

4 doses

2, 4, 6

and

12-15 months

38

IPV vaccine

2 months

4 months

6-18 months

4-6 years

39

MMR 

Varicella

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

40

Hepatitis A

1st dose at 12-23 months

2nd dose 6-18 months later

 

-

6 months minimum time between doses

41

Zoster vaccine

Recommended starting age 60 years per ACIP

FDA licensed for adults 50 years and older 

42

Adults

Pneumonia vaccine

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)

43

Pack year history for tobacco

PPD x years smoked

44

Highest rate of suicide in which population

Males > 65 years

45

Precontemplation stage

Pt not interested in change

Unaware of problem

Minimizes impact

46

Contemplation stage

Considering change

Feels stuck

HCP to examine barriers

47

Preparation stage

Some change behaviors

Does not have tools to proceed

HCP to assist in finding tools, removing barriers

48

Action stage

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

49

Maintenance/relaps stage

Has adopted and embraced healthy habit

Relapse can occur

HCP to continue positive reinforcement

Backsliding is common but not insurmountable

50

USA leading cause of death

Heart Disease

Cancer a close second d/t rising gero population

51

Leading Cancer Cases and Deaths

Cases

Male: Prostate, Lung, Colon

Female: Breast, Lung, Colon

 

Deaths

Male: Lung, prostate, colon

Female: Lung, breast, colon

52

Next step: unexplained bleeding in postmenopausal woman

EMB

53

Breast Ca Screening

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

54

Colon cancer screening

General population

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

 

55

Colon cancer screening

High risk

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

56

Prostate cancer screening

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

57

Endometrial cancer screening

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

58

Lung cancer screening

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

59

Cervical cancer screening

PAP smear starting age 21 every 3 years

Cytology + HPV every 5 years starting 30 years of age

60

Erythropoietin source

90% renal, 10% hepatic

Diminished in advancing renal failure, usually beginning when GFR < 49 mL/min

61

First thing to respond after anemia correction (e.g. in iron deficiency)

Reticulocyte count responds in 1 week

Hgb in 1 month 1gm/dL per month

Ferritin in 4-6 months

62

Drugs then can cause B12/iron malabsorption causing anemia

Chronic PPI use
Long-term Metforming use

63

B12 stores

7+ years of B12 stored in liver

will take 7+ years to be depleted

64

Most common cause of spit-up and vomiting in young infant

GI immaturity allowing reflux

65

Peak risk for hypoglycemia for short-acting rapid insulin (insulin aspart)

1-3 hours after injection

66

Most important measure in Hep C prevention

Use of single-use injection drug paraphernalia

67

Exenatide contraindication

Gastroparesis

68

Belimumab

B-lymphocyte stimulater-specific inhibitor

first biologic agent approved for adults with SLE

69

Cluster Headache

AKA: Migrainous neuralgia, Suicide headaches

Only primary headache M > F

Most common in middle-aged men, likely underdiagnosed in women

70

Triptans in pregnancy

Contraindicated in pregnant women d/t potential vasoconstrictor effects

71

Raynaud disease epidemiology

Most often found in women

Condition usually appears between age 15 and 45

72

Addison's

Primary adrenal insufficiency

 

Key risk factor: autoimmune conditions

E.g. chronic thyroiditis, dermatitis herpetiformis, Graves, hypoparathyroidism, myasthania gravis, Type I DM

73

Next step, microcytic anemia

Ferritin

74

Fatigue, spoon-shaped nails

Iron deficiency anemia

75

Most common for of IDA 4 years and older

Chronic low volume blood loss

76

Most common type of anemia in the elderly

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

77

Haptoglobin is ordered when considering

Hemolytic anemia

78

Most important source of body's iron supply

Recycled iron content from aged RBCs

85% typically comes from old RBCs

79

B12 Deficiency typical MCV

MCV > 125

(most macrocytic)

80

When does RDW normalize after tx

RDW starts to normalize as soon as tx started

81

Iron supplementation

How to take

enteric coating

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

82

Cooley Anemia

Beta thalassemia major

Life threatening w/o intervention

dx shortly after birth

83

Acute rhinosinusitis

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

 

84

ABRS

How common

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

85

Acute ABRS

Risk for DRSP Factors

Age < 2 or > 65

Prior abx in the past month

Prior hospitalization within past 5 days

Comorbidities

Immunocompromised

86

Transillumination for ABRS

Disproven as diagnostic for sinusitis

87

ABRS First line tx

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

88

CYP450 inhibitors

Erythromycin

Clarithromycin

 

Increases toxicity

e.g.

Clarithro + Statin = 15x statin dose = rhabdo

89

Manifestation of IgE mediated allergy

Hive-form/urticaria

Angioedema

90

CYP450 inducers

Pushes substrate OUT the exit pathway
 = decreased substrate levels

 

E.g.

St. John's Wort

91

Presbycusis changes

slowly progressive, symmetric, predominantly high frequency hearing loss

92

Conductive hearing loss

Reversible

Something in between sound and auditory apparatus

OME: can persist for up to 3 months; treatment is TIME

93

Presbycusis describe

Inability to discriminate human voice in a noisy environment

During exam, HCP to:

face-to-face

Eye-level

quiet environment

94

Allergic Rhinitis

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

95

Allergic Rhinitis Tx

First Line

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

96

First generation antihistamines

Diphenhydramine, Chlorpheniramine, Brompheniramine, Hydroxyzine

 

Blocks histamine-1 receptor sites

Significant SE: sedation, impairs performance, ANTICHOLINERGIC effects

Problematic in older adult

97

Ophthalmic antihistamines

Olopatadine (Patanol, Pataday)

For ocular allergy symptoms

Drop might sting for a few seconds

Will not sting once inflammation goes down
 

98

Oral decongestants

Alpha-adrenargic AGONIST

Relieves congestion via vasoconstriction

Caution w/ elderly, young children, HTN, bladder neck obstruction, glaucoma, and hyperthyroidism

99

Nasal decongestants

Afrin

Effective in ABRS

Rebound congestion/rhinitis may occur

LIMIT USE TO 5-7 days

 

100

Anticholinergic effects

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)

101

Lymph node concerning for malignancy

Painless

Firm

Immobile

102

Oral cancer

90% squamous cell

103

CN I

Olfactory

 

104

CN II

Optic

105

CN III

Oculomotor

Eyelid and eyeball movement

106

CN IV

Trochlear

Turns eye downward and laterally

107

CN V

Trigeminal

 

Chewing

Face, mouth sensation and pain

108

CN VI

Abducens

 

Turns eye laterally

109

CN VII

Facial

 

Facial expressions, secretion of tears, saliva, taste

110

CN VIII

Acoustic

 

Hearing, equilibrium, sensation

111

CN IX

Glossopharyngeal

 

Taste, senses carotid BP

112

CN X

Vagus

 

Senses aortic BP

Slows HR

Stimulates digestive organs, taste

113

CN XI

Spinal accessory

 

Controls trapezius and sternocleinomastoid

Controls swallowing movements

114

CN XII

Hypoglossal

 

Controls tongue movements

115

Describe ophthalmic emergency

Red Eye

Painful

Acute vision change

116

Macular degeneration

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

117

Open-angle glaucoma

Describe

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

118

Open-angle glaucoma

Risk Fx

African ancestry

DM

Family Hx

History of eye trauma/uveitis

Advacing age

119

Closed-angle Glaucoma

s/sx

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

120

Drugs that increase IOP

Anticholinergics

Steroids

Sympathomimetic pupil dilating drops

TCAs

MAOIs

Antihistamines

Antipsychotic meds

Sulfonamides

Antispasmolytic agents

121

Open-angle glaucoma Tx

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

122

Angle-closure glaucoma Tx

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

123

Ruptured TM otitis media tx

Ofloxacin otic 10 drops BID x 14 days

 

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

124

Fungal otitis externa tx

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

125

Anosmia

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

126

Senile cataracts

Lens clouding

Progressive vision dimming

Risk Fx: tobacco, poor nutrition, sun exposure, systemic steroids

Potentially correctable w/ surgery, lens implant

127

Presbyopia

Hardening of lens

Near all 45 years and older need reading glasses

128

Suppurative Conjunctivitis common pathogens (nongonococcal/chlamydial)

S. aureus

S. pneumo

H. influenzae

Outbreaks d/t atypical S. pneumo

129

Suppurative conjunctivitis (nongonococcal/chlamydial)

Tx

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.

 

130

Otitis media w/ puctured TM

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

131

Exudative pharyngitis

Causes

Group A, C, G strep

Viral

HHV-6

M. Pneumo

132

Strep pharyngitis tx

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

133

First generation cephalosporins

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

134

Second generation cephalosporins

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

135

Third generation cephalosporins

 

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

136

Fourth generation cephalosporin

Cefepime

Only one

 

 

137

Fifth generation cephalosporin

Ceftaroline

138

Malignant otitis externa

(HIV, DM, chemo)

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

139

Otitis externa tx

general population/immunocompetent

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

140

Otitis Externa Prevention

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

141

Allergic Rhinitis and antihistamines

Will help with itchy/watery eyes, sneezing and rhinorrhea

Antihistamines will not help with nasal congestion

142

Derm assessment questions

 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?

143

Primary Lesions vs Secondary

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

144

Auspitz sign

Psoriasis

Pinpoint bleeding when scale is scraped off.

145

Vitiligo

Autoimmune against melanocytes

Common w/ other autoimmune diseases (thyroid)

146

Palpable Purpura

NEVER BENIGN

"blueberry muffin" appearance

e.g. Meninigitis rash

147

Macule

flat, nonpalpable discoloration

e.g.

Freckle

148

Papule

Solid elevation

e.g.

raised nevus

149

Umbilicated

Papule with indented center

e.g.

Molluscum contagiosum

150

Pustule

Vesicle-like lesion with purulent content

e.g.

Impetigo

151

Patch

> 1 cm

flat, nonpalpable discoloration

e.g.

Vitiligo

152

Plaque

> 1 cm

Raised lesion, same or different color of surrounding skin, can result from coalescence of papules

e.g.

Psoriasis

153

Bulla

> 1 cm

Fluid filled (bigger than vesicle)

e.g.

Necrotizing fasciitis

154

Cyst

Any size

Raised, enxapsulated, fluid-filled lesion

Always benign

e.g.

Intradermal cyst

155

Wheal

Any sized

Circumscribed area of skin edema

e.g.

Hives

156

Purpura

Purpura > 1 cm

Petechiae

Flat red-purple discoloration caused by RBCs lodged in the skin

Do NOT blanch

(vascular lesion = blanches)

 

157

Excoriation

Linear, raised, often covered with crust.

e.g.

scratch marks over pruritic areas

 

158

Crust

Raised lesions produced by dried serum and blood remnants

e.g.

scab

159

Lichenification

Skin thickening usually found over pruritic or friction areas

e.g.

Callus

160

Scales

Raised superficial lesiosn that flake with ease

e.g.

Dandruff

161

Erosion

Loss of epidermis

e.g.

area under vesicle

162

Ulcer

Loss of epidermis AND dermis

e.g

arterial ulcer

Chancre

163

Fissure

Narrow linear crack into epidermis, exposing dermis

e.g.

athletes foot

164

Annular lesion

In a RING

e.g.

Erythema migrans ("bull's eye") in Lyme disease

165

Scattered lesion

Generalized over body w/o specific pattern or distribution

e.g.

maculopapular rash in rubella

166

Confluent/coalescent lesions

Multiple lesions bleding together

167

Clustered lesions

Occurring ina group with pattern

e.g.

Acne-form drug induced rash

seen with lithium, phenytoin, and iodine use = anticipated adverse effect

168

Linear lesions

 In streaks

e.g.

Contact dermatitis poison ivy

169

Reticular lesions

Appearing in a net-like cluster

e.g.

Erythema infectiosum (Fifth Disease/slapped cheek)

170

Dermatomal or zosteriform lesion

 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

171

Varicella

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

172

Zoster (shingles)

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

173

Actinic Keratoses (AK)

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

174

Basal cell carcinoma

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

175

Squamous cell carcinoma

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

176

ABCDE

Malignant Melanoma

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

177

Psoriasis vulgaris tx

medium-potency topical corticosteroid

178

Rosacea tx

Topical metronidazole

179

Pityriasis rosea

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

180

Acanthosis nigricans

cutaneous manifestation of hyperinsulinemia

puberty = worsenign insulin resistance

can regress w/ control of disease

e.g. after gastric bypass

181

Erysipelas

Infection of upper dermis, superficial lymphatics

Streptococcus pyogenes (aka GABHS)

182

Cellulitis

Infection of dermis and subcutaneous fat

Streptococcus pyogenes, less commonly MSSA beta-lactamase producing, MRSA (resistance via altered protein-binding sites)

183

Cutaneous abscess, furuncle

Skin infection involving hair follicle and surrounding tissue

Carbuncles = cluster of furuncles connected subcutaneously, causing deeper suppuration and scarring

Staph aureus (MSSA, MRSA)

184

Nonpurulent skin infection

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

185

Purulent skin infection

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

186

Brown Recluse Spider Bite

"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

187

Most common cause of new onset ulcerating skin lesion across North America

MRSA

188

Nafcillin

Narrow spectrum

Beta-lactamase resistant PCN

Use of not risk factors for MRSA

189

Rocky mountain spotted fever

s/sx and dx

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

190

Rocky mountain spotted fever

Tx

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

191

Lyme disease

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

192

CA-MRSA tx

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)

193

Babies

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

194

Sun safety

Children > 6 months and adults

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)

195

Hypothyroidism

s/sx

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

196

Hypothyroidism etiology

Hashimoto thyroiditis (most common) = autoimmune

Post-radioactive iodine (RAI) = s/p Graves disease tx or thyroid ca tx

Select medication use = lithium, amiodarone, interferon

197

Hyperthyroidism

s/sx

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

198

Hyperthyroidism

Etiology

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)

199

TSH

Normal values

0.4 to 4.0 mIU/mL

200

TSH test evaluates what

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

201

Free T4

NL = 10-27 pmo/L

Unbound, metabolically active portion of thyroxine

About 0.025% of all T4

202

Total T4

Rarely indicated

Total of protein-bound and free thyroxine

Often altered in the absence of thyroid disease

203

Free T3

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

204

Total T3

 

Rarely indicated

Reflects total protein-bound and free triidothyronine (T3)

Often altered in the absence of thyroid disease

205

Antiperoxidase antibody

(antimicrosomal, antithyroid, thyroperoxidase)

 

Test to help detect autoimmune thyroid disease

Measures an antibody against peroxidase, an enzyme held within the thyroid

206

Levothyroxine replacement

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

 

207

Hyperthyroidism

Test results and Tx

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

 

208

Subclinical hypothyroidism

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

209

Goal TSH

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

210

Thyrotoxicosis arrhythmia

atrial fibrillation

211

Risk of malignancy thyroid nodule

5%

(similar to breast bx rates)

212

Malignant thyroid nodule characteristics

history of head or neck irradiation

Size > 4 cm

Firmness, nontender

Immobile

Persistent, nontender cervical

213

Thyroid nodule

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

 

214

Headache Red Flags

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

215

Tension h/a

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

216

Migraine w/o aura

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%

217

Migraine w/ aura

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%

218

Cluster h/a

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%

219

Pressing non-pulsatile pain h/a

Tension

220

Usually bilateral h/a

Tension

221

Pulsating pain

Migraine

222

Hot poker feeling in one eye h/a

Cluster

223

Nausea and photophobia w/ h/a

Migraine

224

Usually unilateral h/a

Migraine (90% favor one side)

Cluster

225

Nasal stuffiness w/ conjunctival injection h/a

Cluster

226

Lifestyle modifications for primary h/a

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

227

Analgesic use in primary h/a

NSAIDs, APAP, others

Limit use to 2 tx days/week to avoid analgesic rebound h/a

228

Triptans

Ergot derivatives

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)

229

Primar h/a prophylactic (controller) medications

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

230

Indiations for primary h/a prophylaxis

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

231

NP when to refer

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)

232

CT w/o contrast of head

Reveals:

Acute hemorrhage

Chronic hemorrhage

Edema, shift

Atrophy

Ventricular size

Emergent image to r/o bleed: CT w/o contrast

233

CT w/ contrast of head

Reveals: tumor, abscess

234

MRI of head

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

235

Migraine and OCPs

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

236

Giant Cell Arteritis

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

237

Typical BP pain response

SBP elevated but DBP is at/close to baseline

238

Riboflavin and Magnesium for migraine prevention

Riboflavin 500 mg 

Magnesium 250-350 mg 

for 6-8 weeks

--

Mg - might loosen stools

Riboflavin - glow urine

239

GCA mgmt

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

240

Pain on chewing

Jaw claudification in GCA

 

241

Potential dietary triggers primary h/a

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

242

Lifestyle triggers, primary h/a

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

243

GERD Dx

Typical sx of heartburn/regurg

H. pylori screening not recommended in typical GERD

Upper endoscopy not required in typical GERD sx

 

244

When to order upper endoscopy in GERD

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

245

GERD mgmt

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

246

H. pylori and which ulcers?

95% of all duodenal ulcers =

H. pylori

247

Neutrophilia 

Elevated in Bacterial infection

NL :

248

Lymphocytosis

Elevated in Viral infection

NL:

249

Monocytosis

Elevated in Debris removal

Good sign during recovery after illness

NL :

250

Eosinophilia

Elevated in Allergens, parasites

("worms, wheezes, and weird diseases")

NL:

251

Basophilia

elevated in Anaphylaxis, not fully understood

NL:

252

Blumberg's sign

LATE peritoneal sign

Deep palpate area of abd tenderness

Pain upon release = peritoneal inflammation

AKA: rebound tenderness

253

Markle's Sign

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"

254

Murphy's sign

Painful arrest of inspiration triggered by palpating edge of inflamed gallbladder

255

45 y/o male

Drinks 8-10 beers/day

12 hour history of acute onset epigastric pain radiating to back w/ bloating, N&V

Epigastric tenderness, hypoactive bowel sounds, abdomen distended and hypertympanic

Elevated lipase, amylase

Dx?

Acute Pancreatitis

 

"Boring epigastric pain to the back"

ETOH use

256

64 y/o F 

3-day hx of intermittent LLQ abd pain w/ feer, cramping, nausea, 4-5 loose stools/day

Soft abdomen, +BS, LLQ tenderness w/o rebound

Leukocytosis, neutrophillia

Dx?

Acute Diverticulitis

-

 

Cover for anaerobes and gram negative bacteria:

Cipro + Flagyl

257

34 y/o M

3 month hx of intermitten upper abdominal pain described as epigastric burning, gnawing pain 2-3 h PC, relief w/ foods, anatacids.

Awakens 1-2 AM w/ sx

Tender epigastrum, LUQ

Slightly hyperactive BS

Dx?

Duodenal ulcer

-

Check for H. Pylori

RELIEF w/ FOOD

258

52 y/o F

Recently laid off, 3-4 Ibuprofen/day for 2-3 months to help w/ headaches

1 month hx of intermittent nausea, burning, and pain, limited to upper abdomen, worse w/ eating

Tender epigastrum, LUEQ, hyperactive BS

Dx?

Erosive gastritis

-

D/C NSAIDs

May check H. Pylori

WORSE w/ FOOD

259

21 y/o F

2 month hx of intermittent crampy abd pain, diarrhea, weight loss, fatigue

3 day hx of increasing discomfort, fever, tenesmus (sensation of incomplete bowel emptying)

Pale conjunctiva, tachycardia, slightly hyperactive BS, diffus abd tenderness w/o rebound

Normocytic, normochromic anemia, leukocytosis w/ neutrophilia

Inflammatory Bowel Disease

-

TOXIC MEGACOLON - anemia, leukocytosis w/ neutrophilia

Need hospital admission

260

Pancreatic ca risk fx

Hx of chronic pancreatitis

Tobacco use

DM

261

Most efficient route of transmission for hep C

Blood transfusion

Vertical transmission (mom to nursing infant) = uncommon

 

262

Vertical transmission

Mom to nursing infant

263

Horizontal transmission

Person to person

e.g. sexual contact

264

Hep A transmission

Fecal-oral

265

HBsAg positive 

Hep B surface antigen +

=

HBV is present

266

Anti-HBc positive

Anti-Hep B core

=

ongoing Hep B infection

267

Infectious hepatitis liver enzymes

ALT > AST

Acute hep B infection = markedly elevated LFTs

268

Hep A transmission

ingestion of fecal matter via

close person to person contact w/ infected person

Sexual contact w/ infected person

Ingestion of contaminated food/drinks

269

Hep A risk fx

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

270

Hep A incubation period

15 to 50 days 

Avg: 28 days

271

Viral hepatitis clinical sx

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

272

Hep A risk for chronic infection

None

Most recover w/ no lasting liver damage

Rarely fatal

No chronic disease

273

Hep A test for acute infection

IgM anti-HAV

274

Hep B transmission

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

275

Hep B risk fx

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

276

Hep B incubation period

45 to 160 days

avg: 120 days

277

Hep B risk for chronic infection

> 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

278

Hep B test for acute infection

HBsAg in acute AND chronic +

IgM anti-HBc + in acute infection only

279

Hep C transmission

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

280

Hep C risk fx

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

281

Hep C incubation period

14 to 180 days 

avg: 45 days

282

Hep C risk for chronic infection

75-85% of newly infected persons will develop chronic infection

15-25% will clear virus

283

Hep C acute illness

Uncommon

Those who do develop acute illness recover w/ no lasting liver damage

No serologic marker for acute infection

284

Hep C and chronic liver disease

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

285

Hep B test for chronic infection

HBsAg

also positive in acute infection

and additional markers as needed

IgM + in acute infection ONLY

286

Hep C test for chronic infection

Screening assay (EIA or CIA) for anti-HCV

Verify by more specific assay (NAT for HCV RNA)

287

Hep B screening 

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

288

Hep C screening

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

 

289

Hep A vaccine

2 doses 6 months apart

Recommended for all children at age 1 year

Travelers

Men who have sex w/ men

Clotting factor disorders

290

Hep B vaccine

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

291

Hep A Tx

No medication available

Supportive

292

Hep B Tx

Acute: no medication available, supportive

Chronic: Regular monitoring for signs of liver disease progression, some patients treated w/ antivirals

293

Hep C tx

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

294

IBS dx

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

295

IBS tx

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

 

296

Ulcerative Colitis Dx

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

 

297

Toxic megacolon

Colonic dilation of > 6 cm on radiographs w/ signs of toxicity

Occurring in

Heightens risk of perforation 

(Ulcerative Colitis)

298

Ulcerative colitis testing

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

299

Ulcerative Colitis Tx - Mild

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

300

UC and colon ca

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

301

Ulcerative Colitis - Severe Tx

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

 

302

Crohn Disease dx

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

303

Crohn disease labs/tests

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%

 

304

Intestinal obstruction s/sx

postprandial bloating, cramping pains, loud borborygmi

Narrowing small bowel may occur as a result of inflammation, spasm, or fibrotic stenosis

305

Crohn's tx

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)

306

H. pylori tx

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.

307

Diverticulitis dx

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

 

308

Peptic Ulcer Disease dx

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

309

Diverticulitis tx - MILD

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

310

Diverticulitis tx - SEVERE

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

311

Diverticulitis prevention 

High fiber diet

312

Diverticulitis when to admit

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

313

Non-invasive testing for H. Pylori

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

314

H. pylori and gastic cancer

2-6x higher risk for gastric cancer in presence of H. pylori


90% of gastric adenocarcinoma of stomach have positive H. pylori

315

Mitral regurgitation

Describe

Best auscultated w/ diaphragm 

Lower border of the right scapula

Systolic murmur

High pitched murmur

316

Levothyroxine dosing

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

317

Spleen normal weight, size, and location

"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

318

High purine foods

(Avoid in gout)

scallops, mussels

organ meats and game meats

beans

spinach

asparagus

oatmeal

baker's and brewer's yeasts

319

Infectious endocarditis abx prophylaxis

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

320

GERD alarm sx

Dysphagia

Odynophagia (painful swallowing)

GI bleed

Unexplained weight loss

Persistent chest pain

321

Expected findings in bacterial meningitis

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

322

Expected findings in viral or aseptic meningitis

Normal CSF glucose level

Modest elevation in CSF protein

323

3rd degree burns

describe

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

white and leathery

324

2nd degree burns

describe

Raw and moist

Painful

325

Most potent risk factor for arterial occlusive disease caused by extensive atherosclerosis

Tobacco use

Other risk fx:
DM, HTN, HL

326

Heatstroke tx

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

327

STEMI mgmt

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

328

Dihydropyridine CCBs

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

329

Non-dihydropyridine CCBs

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

330

Troponin I

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

331

CK-MB

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

332

Lateral epicondylitis

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

333

CAP likely organisms

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 -)

334

Most common cause of fatal CAP

Streptococcus pneumoniae

Gram + diplococci

335

Strep pneumo tx

CAP

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

336

Greatest impact on HIV transmission

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

 

337

Typical SSRI symptoms

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

338

shingles vaccine

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

339

ACOG recommendation on TSH in pregnant women

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)

340

Quinolone abx CV risk

All quinolones have potential to produce QT prolongation

Prescribe w/ caution in older adults

341

Hesselbach's triangle

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

342

Common complaint in older pts w/ cataracts

sunlight sensitivity

343

Most common site for indirect inguinal hernia

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

344

acute, painless groin swelling

high yield test?

Ultrasound of scrotum

Ddx: inguinal hernia, hydrocele, varicocele

U/S will yield quick, relaible information w/ dx accuracy of 93% for groin problems

345

Carotid bruit significance

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

346

Best tx for isolated systolic HTN

Amlodipine - long acting CCB

Dihydropyridines

--

Thiazides are not potent enough and effect is not additive when combined with CCBs

347

ACE inhibitors in HF

Monitor what?

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

348

Goal postprandial glucose in older adults

 

349

MRI in back pain

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

350

H. Influenzae tx

Gram-negative bacillus

30% produce beta-lacatamase

Effective abx:

Cephalosporins

Augmentin

Macrolides

Resp. fluoroquinolones

tetracyclines including doxy

351

Common respiratory pathogen in smokers

H. Influenzae (gram -)

 

352

M. pneumo and C. pneumo tx

(atypicals)

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

353

Atypical CAP

transmission

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)

354

Legionella sp.

Transmission

Tx

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

355

Petit mal seizures

Describe

Absence seizure

Blank stare 3-50 seconds w/ impaired level of consciousness

Usual age of onset 3-15 years

356

Myoclonic seizures

describe

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

357

Focal or simple seizures

describe

aka jacksonian seizures

awake state w/ abnormal motor, sensory, autonomic, or psychic behavior

movement can affect any part of body, localized or generalized

 

358

Complex partial seizures

describe

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

359

Bursae

Function

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

360

Levodopa and Parkinson disease mgmt

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

361

Medications that may precipitate gout by causing hyperuricemia

Thiazide diuretics

Niacin

ASA

Cyclosporine

ETOH

362

Causes of secondary gout conditions

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

363

Smallpox

Describe

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

364

resting state normal stomach pH

pH: 2

Production:

1-2 mEq/hour in resting

increases to 30-50 mEq/hour after a meal

365

Minimum diagnostic for CAP

CBC w/ diff

CXR

Additional testing based on patient presentation and comorbidity

366

Likely causative pathogen CAP

Previously healthy

No recent systemic abx (within 3 months)

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

367

Likely causative organisms CAP

Comorbidities (COPD, DM, renal, HF, asplenia, alcoholism, immunosuppressing conditions/medications, malignancy)

Systemic abx in past 3 months

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)

368

CYP34A inhibitors

abx

Erythromycin

Clarithromycin

-

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

369

pulse pressure significance

wide = Good circulating fluid volume

narrow = dehydration

370

Physical Findings PNA

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

371

Pleural inflammation (pleurisy)

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

 

372

Acute bronchitis likely pathogen

Respiratory tract viruses 90%

Bacteria - M. Pneumo, C. Pneumo, B. pertussis 10%

373

Acute bronchitis tx

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

374

Define Asthma

Common chronic disorder of the aiways

Variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation

Inflamamtion causes the bronchospasm

375

Asthma s/sx, dx

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

 

376

Asthma visit frequency

well-controlled: 3-6 months

not well-controlled: 2-6 weeks

377

ICS in Asthma

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

378

ICS/LABA in asthma

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

379

Leukotriene receptor antagonists

Leukotriene modifiers

Montelukast (Singulair)

Zafirlukast (Accolate)

Additional benefit w/ allergic rhinitis, most often used in conjunction with ICS

not useful as solo therapy

380

How much is systemically absorbed ICS

20% of a relatively small dose in ICS

381

LTRAs vs ICS in antiinflammatory effect

ICS at least 2-3x more potent than LTRAs

LTRAs only prevents Leukotriene whereas ICS prevents at least 8 inflammatory mediators

382

SABA in Asthma

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

383

SABA how to use

  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

384

Systemic corticosteroids in Asthma

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

385

Most common reason for asthma flare

Viral respiratory infection

Typically 5-7 days viral infection would clear

386

Anticholinergics in asthma

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

387

Theophylline in asthma

mild to moderate bronchodilator

cheap but requires blood draws for monitoring

multiple drug-drug interaction potential

388

Intermittent Asthma

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

389

Mild persistent asthma

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

390

Moderate persistent asthma

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

391

Severe persistent asthma

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

392

Step 1 asthma

Intermittent asthma

SABA PRN

393

Step 2 asthma

Mild persistent

Low dose ICS

+ SABA PRN

 

alternatives: Cromolyn, LTRA, nedocromil, thophylline

394

Step 3 asthma

Moderate persistent

Low-dose ICS + LABA

or

Medium dose ICS

 

Alternative: low-dose ICS+LTRA/theophylline/Zileuton

395

Step 4 asthma

Severe persistent

Medium dose ICS + LABA

Alternative: Medium-dose ICS + LTRA/theophylline/Zileuton

396

Step 5 asthma

High dose ICS + LABA

AND

Omalizumab for patients who have allergies

397

Step 6 asthma

High dose ICS + LABA + oral corticosteroids

AND

consider Omalizumab for patient who have allergies

398

When to step up/down in asthma

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

399

Findings in diseases of air-trapping

e.g. asthma, COPD

Hyperresonance

Decreased tactile fremitus = decreased tissue density

Wheeze (expiratory first, inspiratory later)

Low diaphragm

Increased AP diameter ("barrel chest")

400

COPD describe

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)

401

COPD dx

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

402

COPD and common arrhythmia

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

403

Mild COPD

Describe

GOLD 1

FEV1 > 80% predicated

 

404

Moderate COPD

Describe

GOLD 2

FEV1 50-80%

405

Severe COPD

Describe

Symptomatic

FEV1 30-50% predicted

406

Very severe COPD

Describe

GOLD 4

Symptomatic

FEV1

407

Medications in COPD

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

408

GOLD 1-2 COPD tx

low risk

less sx

1 or

First choice: SAMA or SABA prn

--

SAMA: Atrovent

SABA: Proventil

 

Second choice: LAMA, LABA  or combined SAMA+SABA

Alternative: Theophylline

409

GOLD 1-2 COPD tx

Low risk

More sx

1 or fewer exac/year

LAMA 

or

LABA

2nd choice: LAMA + LABA

Alternative: PDE-4 inhibitor, SABA and/or SAMA, Theophylline (do not use w/ roflumilast)

410

GOLD 3-4 COPD tx

High risk

Less sx

2 or more exac/year

ICS + LABA

or

LAMA

 

2nd choice: ICS+LAMA, ICS+LABA+LAMA, ICS+LABA+PDE4 inhibitor etc.

Alternative: Carbocysteine (mucolytic) SABA and/or SAMA, theophylline

411

Theophylline in COPD

Do not use with PDE4 inhibitor roflumilast

412

Oxygen in COPD

When

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%)

413

COPD exacerbation 

Define

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

414

COPD exacerbation TX

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

415

Abx potentially associated w/ QT prolongation and increased risk of CV death 

Macrolides

416

Abx w/ potential for tendon rupture, particularly when taken w/ systemic corticosteroid

Respiratory fluoroquinolones

417

Abx for COPD Flare

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

418

Inhaled anthrax

s/sx

Low grade fever, nonproductive cough, nonspecific presentation

Widened mediastinum d/t hemorrhage visile on CXR or thoracic CT
Tx:

Fluroquinolone

Expert consult

419

Cutaneous anthrax

Most common form

pustular skin lesion that eventually forms ulcer w/ eschar

tx:

Fluoroquinolone

expert consult

420

Post-infectious cough tx

Atrovent

If no relief add ICS

if inadequate response, PO prednisone

last line: codeine+dextromethorphan

421

Botulism

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)

422

Type 1 DM

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

423

Type 2 DM

Insulin resistance w/ eventual insulin deficiency

Few if any sx

Usually dx during routine screening

424

DM screening criteria

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

425

DM dx

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

426

Pre-DM

IFG = 100 to 125 mg/dL

IGT= 140 to 199 mg/dL on 75g OGTT

A1C = 5.7 to 6.4

427

DM Goals

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

428

A1C and Estimated Average Glucose

6% = 126

7% = 154

8% = 183

12% = 298

429

Biguanide

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

 

430

Thiazolidinedione (TZD, glitazones)

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

431

Sulfonylrea (SU)

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

432

Meglitinides

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

433

Dipeptidyl peptidase-4 inhibitor (DPP-4)

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

 

434

GLP-1 agonist

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

435

Alpha-glucosidase inhibitors

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

436

Sodium glucose contransporter-2 (SGLT2)

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

437

When to start insulin

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

438

Basal insulin percentage

50%

439

Humalog

Lispro insulin

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

440

Insulin Aspart

Novolog

Short acting

Onset 10-20 minutes

Give 5-10 minutes before meals

Peak 1-3 hr

Duration 3-5 hr

441

Insulin glulisine

Apidra

Short acting

Onset 10-15 min

give within 15 minutes or right after meals

Peak 1-1.5 hr

Duration 3-5 hr

442

Regular insulin

Humulin R

Novolin R

Short acting

Onset 30 min-1 hr

Peak 2-3 hr

Duration 4-6 hr

443

NPH

Novolin N

Humulin N

Intermediate acting

Onset 1-2 hr

Peak 6-14 hr

Duration 16-24 hr

444

Insulin glargine

Lantus

Long-acting

Clinical effect 1 hr

No peak

Duration 24 hours

445

Insulin detemir

Levemir

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

446

Metabolic syndrome components

Large waistline

Hypercholesterolemia

Low HDL

High BP

High glucose

447

Meningomyocele

 

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

448

Myelocele

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

449

Omphalocele

abdominal wall defect

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

450

What shoulder movement to test supraspinatus, anterior and lateral deltoid, and pectoralis major?

Shoulder abduction

451

DM quality indicators/additional care considerations

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

452

Metabolic Syndrome


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

453

Creatinine increase

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

454

Nonproliferative diabetic retinopathy

microaneurysms, macular edema

visual loss d/t macular edema

455

Proliferative diabetic retinopathy

new fragile vessels form

456

DM retinopathy w/ fluid leak/bleed/macular edema vision changes and tx

New onset blurry vision

"floaters" "holes" "swiss cheese" vision

Tx

tight BG control

photocoagulation

Vitrectomy if disease progresses after photocoagulation

457

HTN target organ damage examples

Stroke, vascular (multi-infarct) dementia (20% of all dementias)

Atherosclerosis, MI, LVH, HF

HTN nephorpathy, renal failure

HTN retinopathy w/ risk of blindness

458

Grade 1 HTN retinopathy

Narrowing of terminal branches

No vision change or permanent fidings

459

Grade 2 HTN retinopathy

Narrowing of vessels w/ severe local constriction

No vision change or permanent findings

460

Grade 3 HTN retinopathy

Preceding signs w/ striate hemorrhages and soft exudates

Potential for visual change and permanent findings

Black spots in visual field

pending HTN crisis - 911

461

Grade 4 HTN retinopathy

Papilledema w/ preceding signs w/ striate hemorrhages and soft exudates

Potential for visual change and permanent findings

pending HTN crisis - 911

462

Weight reduction in HTN and HL

Maintain normal body weight

SBP reduction 5-20 mmHg per 10 kg weight loss

463

DASH eating plan for HTN and HL

Rich in fruits and vegetables, low-fat dairy, reduced saturated and total fat

SBP reduction 8-14 mmHg

464

Dietary sodium restriction in HTN and HL

SBP 2-8 mmHg reduction

465

Aerobic physical activity for HTN and HL

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

466

Moderate ETOH consumption in HTN and HL

M

F

SBP reduction 2-4 mmHg

467

BP goal

DM/CKD tx

Black vs Nonblack tx

 

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

 

468

BP titration

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

469

Thiazide diuretics

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

470

ACEIs and ARBs

ACEIs: Lisinopril, Enelapril (Vasotec)

ARBs: Losartan (Cozaar), telmisartan (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

471

Calcium channel blockers CCBs

MOA: causes vasodilation

Dihydropyridine (DHP): Amlodipine (Norvasc), felodipine (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

472

Betablockers

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

473

Aldosterone antagonist

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

474

Centrally-acting BP agents

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

475

Cumin and coriander

No documented drug interactions

Lowers BP in large doses

Ok to use

476

Lipid affected by non-fasting state

Triglycerides

477

Saturated fats

Solid at room temp

Avoid tropical oils such as palm and coconut oil

478

Dietary options to decrease LDL

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

479

HL fat intake

Reduce saturated fat to

Avoid trans fats

Reduce total cholesterol intake to

Dietary fat to 25-25% of total daily caloric intake

480

Omega-3 in HL

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

481

High dose statin

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%

 

482

Moderate dose statin

indicated if > 75 y/o with clinical ASCVD

or

DM 40-75 y/o LDL

 

483

Statin Tx LDL reduction

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

484

Statin Tx considerations

HMG CoA reductase inhibitor

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

485

Grapefruit juice

intestinal CYP450 34A inhibitor

caution w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)

486

Bile acid resins (sequestrants)

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

487

Selective cholesterol absorption inhibitor

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

488

Niacin

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

489

Fibric acid derivatives (Fibrates)

 

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

490

Fish Oil (omega-3 fatty acid)

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)

491

Heart Failure Classes

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

492

HF Class I

No sx

Tx: primary prevention, treat risk factors

493

HF Class II

Sx w/ moderate activity

Tx: Add ACE/ARB and BB if not already taking

494

HF Class III

Class IIIa = Sx w/ ordinary activity

Class IIIb = sx w/ minimal activity

Tx: Add diuretics, Digoxin, Nitrates, Hydralazine

Consider biventricular pacing and implantable defibrillator

495

HF Class IV

Sx at rest, w/ no activity

Tx: Hospice, heart transplant, chronic inotropes (Dobutamine clinic), permanent pump (LVAD)

496

Stage A HF

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

 

497

Stage B HF

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

498

Stage C HF

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

499

Stage D HF

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

500

Physiologic murmur describe

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

501

Aortic stenosis murmur describe

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

502

MRPASS wins MVP

Mitral

Regurgitation

Physiologic

Aortic

Stenosis

Systolic

 

Mitral

Valve

Prolapse

503

MSARD

Mitral

Stenosis

Aortic

Regurgitation

Diastolic

504

Aortic Sclerosis describe

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

505

Aortic regurgitation murmur

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

506

Mitral stenosis

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

507

Infective endocarditis prophylactic abx indication

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

508

IE prophylactic tx before dental/oral/respiratory tract/esophageal procedures

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

509

Atrial septal defect

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

510

Pulmonary HTN

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

511

Mitral regurgitation

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)

512

Mitral Valve Prolapse

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

513

Normal vaginal pH

3.8-4.2
 in reproductive age

514

Candida vulvovaginitis

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

515

Bacterial Vaginosis

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)

516

Height and age for adult seat belts

57 inches

8-12 years

517

Fluconazole is a cytochrome what?

P4502CP inhibitor

518

S. pneumo resistance mechanism

altered protein binding sites

519

Loss of posterior tibial reflex indicates a lesion in what?

L5

520

Tx of tremor and tachy in ETOH witdrawal

Clonidine

521

What is apraxia

impairment of motor activities despite intact motor function

522

bladder cancers superficial w/o mets

despite successful initial tx, local reccurrence is common

523

Glucosamine and chondroitin

cannnot recommend in OA per evidence

524

Evista and osteoporosis

risk of osteoporosis is reduced

selective estrogen receptor modulator

525

Which SSRI might interact w/ Warfarin?

Fluoxetine

Prozac

526

Risk of which thyroid disorder in Down Syndrome

Hypothyroidism

527

SNRI example and mechanism

Effexor

SNRIs increase the levels of norepinephrine and dopamine in the brain

528

How many systems are reviewed in an ROS

10

529

Clean catch urine instructions

clean genital/urinary area w/ cleansing wipe

void some urine before beginning collection

collect from middle of stream

530

5HT3 antagonist

Alosetron

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

531

Describe bronchial breath sounds

high, loud, hollow-sounding

532

Clinically significant stenosis - obstruction of at least what percentage of a major coronary artery or one of its major branches?

70%

533

Obturator sign

evaluation for acute appendicitis

Rotating right hip through full ROM, positive if pain w/ movement/flexion of hip

534

Gabapentin side effects

drowsiness, blurred vision, tremors, tiredness
 usually not cause for concern

Stomach upset and vomiting not typically associated w/ gabapentin

 

535

CHF follow up schedule

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

536

Faun tail nevus

Tufts of hair on a child overlying spinal column

may be sign of spina bifida occulta

537

Presumptive sign of pregnancy

Amenorrhea

Fatigue, nausea, breast changes, urinary frequency, slight increase in body temp

Probable signs of pregnancy: goodell's sign, hegar's sign

538

Uterus growth in pregnancy

1 cm per week after 4 weeks of gestation

6-8 weeks: pear

8-10 weeks: orange

10-12 weeks: grapefruit

539

Goodell's Sign

Softening of cervix d/t increased vascularization

540

Hegar's sign

Nonsensitive sign of pregnancy

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

541

Chadwick's sign

Bluish discoloration of cervix

early sign of pregnancy

6-8 weeks after conception

542

35 y/o abd pain, upper right side, back pain, unexpected weight loss

Most likely dx

Gallstones

543

Ulcerative colitis lifestyles changes

Vitamin supplements and iron

Avoid dairy

Eat nutritious diet - low-residue, low-fat, high-protein, high-calories foods

Avoid smoking, caffeine, pepper, ETOH

544

BUN:Cr ration of >20:1

Most likely dx

Acute glomerulephritis

Also - UA will show renal casts and RBCs

545

Nitrites in UA significance

a surrofate marker for bacteriuria

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

546

SSRI commonly associated side effects

decreased libido and weight gain

TCAs have more weight gain

Jitteriness and restlessness are commonly associated w/ SSRI use

547

Anemia Hgb threshold M and F

Hgb

Hgb

548

TIA describe

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

549

HTN f/u

Once BP is stabilized f/u should be every 3-6 months

Normotensive pts: every 1-2 years

550

Misoprostol

Prostaglandin analogue

Specifically designed for gastric protection with NSAID use

551

Herpes keratitis

Damage to corneal epithelium d/t herpes virus (shingles)

Acute onset eye pain, photophobia, blurred vision in affected eye w/ rash

552

Xanthelasma

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

553

Patient w/ IBS taking both hysocyamine and antacid how to take

take antacid AFTER hysocyamine and after a meal

554

Most common cause of new onset fecal incontinence in elderly

constipation

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

555

Sulfa allergy and HCTZ

HCTZ is contraindicated

HCTZ has a sulfonamide ring in its chemical structure

556

When to order PET scan

Positron emission tomography

Shows brain function and highlights abnormal tissue

Often done after abnormal CT

Evaluates for brain tumor

557

Toxic shock syndrome

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

558

PEF determination factors

Based on HAG

Height

Age

Gender

559

Basal cell ca

Low metastatic risk

Early recognitition and intervention is recommended

Untreated BCC can lead to significant deformities and altered function

560

Prostatodynia

No fever

Dyuria, decreased urinary flow, post-void dribbling, hesitancy

may be associated w/ back pain or pain in testicles

561

Acute gastroenteritis

BRATY diet

Bananas

Rice

Applesauce

Toast

Yogurt

562

MMR vaccine

Safe during lactation

contraindicated in pregnancy

risk exists in theory

563

Max dose Lisinopril

40 mg/day

564

Obesity waist circumference M and F

M > 40 in

F > 35 in

565

Moro reflex

startle reflex

Disappears at 4-6 months

566

S4 heart sound

Low-frequency

Heard late in diastole

rare in infants and children

always pathological

Seen in condition w/ decreased ventricular compliance

567

Folliculitis tx

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

568

Senile purpura

Aka vascular purpura

common and benign condition in the elderly

normal labs

569

Total cholesterol values

Normal

Borderline 200-239

High > 240

570

Acute lymphocytic leukemia points of teaching

 

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

571

Most cost-effective, sensitive, specific test for H. Pylori

organism-specific stool antigen testing

H. pylori transmitted via oral-fecal and oral-oral route

spiral shaped organism

572

Beclomethasone dose HFA

Low: 80-240 mcg

Medium: >240-480 mcg

High: > 480 mcg

573

Secondary HTN evaluation

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

574

Tennis ball uterus size how many weeks

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

575

Still's murmur

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

576

Time frame for suture removal

Arms, hands = 5-10 days

Over a joint = 7-14 days

577

Atrophic Vaginitis

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

578

Risk fx of lumbar radiculopathy

> 50

Male

Overweight

Cigarette smoking

579

what are clue cells

vaginal epithelial cells w/ adherent bacteria

580

Achilles tendon reflex loss

what nerve root is affected

L5 and S1

581

Most common site of cervical radiculopathy

C6 and C7

582

Most common site of lumbar disc herniation

L4 to L5

and

L5 to S1

583

Genital herpes

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

584

Nongonococcal urethritis and cervicitis

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

 

585

Gonococcal urethritis and vaginitis

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

586

Trichomoniasis

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

587

Syphilis organism

Treponema pallidum

588

Syphilis primary stage

Chancre, firm, round, PAINLESS genital and/or anal ulcers w/ clean base and indurated margins

localized lymphadenopathy

3 weeks duration

resolve w/o tx

589

Syphilis Secondary Stage

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

590

Syphilis Latent stage

Variable presentation

Gumma - rare

Occurs when primary and secondary sx have resolved

591

Syphilis Tx

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

592

Genital warts

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

593

Nongenital warts HPV types

HPV types 1, 2, 4

594

HPV types associated w/ GU malignancies

HPV types 16, 18, 31, 33

595

Pelvic inflammatory disease define

Infection of upper female reproductive tract, including uterus, fallopian tubes, adjacent pelvic structures

Causative organisms: N. gonorrhoeae, C. trachomatis, bacteroides, Enterobacteriaceae, streptococci

596

PID clinical findings

Irritative voiding sx

fever, abd pain, CMT, vaginal discharge

possible sequelae include tubal scarring w/ subsequent increased risk for ectopic pregnancy and/or infertility

597

PID tx

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

598

Balanitis

Inflammation of the glans

common in candida to also have scrotal involvement

vs jock itch (tinea cruris) typically no scrotal involvement

599

UTI uncomplicated acute usual pathogens

E. coli (gram neg, most common)

S. saprophyticus (gram pos.)

Enterococci (gram-pos)

600

Acute uncomplicated UTI tx

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!)

601

Acute uncomplicatated pyelonephritis

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

602

Epididymoorchitis

35 y/o and younger

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

603

Epididymoorchitis > 35 y

OR

insertive partner in anal intercourse

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

604

Acute bacterial prostatitis 35 years and younger

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

605

Acute bacterial prostatitis

> 35

low risk for STI

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

606

Normal prostate

firm, smooth

size of walnut

about as firm as tip of nose

607

Acute prostatitis

Tender, boggy, indurated

About as firm as cheekbone

608

Prostate cancer

nodular, firm

Usually malignant lesions are not palpable until disease is advanced

Order testicular U/S then refer to urology

609

Bladder cancer risk fx

Textile worker (dyes)

Smoking

Intermittent painless gross hematuria (90%)

10% microscopic hematuria

610

Treatable causes of urinary incontinence

Delirium

Infection (urinary)

Atrophic urethritis and vaginitis

Pharm (diuretics)

Psychological disorders (depression)

Excessive urine output (HF, DM)

Restricted mobility

Stool impaction

611

Urge incontinence

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

612

Stress incontinence

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

613

Functional incontinence

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

614

Transient incontinence

Assoc. w/ acute event such as delirium, UTI, medication use, restricted activity

Tx of underlying process (e.g. d/c med)

615

ASCUS w/ HPV +

no hx of abn cytology

Last screening 2 yrs ago

next step?

Colposcopy

616

Paraphimosis

Retracted foreskin that cannot be brought forward to cover the glans

Emergency!

617

Varicocele

Palpable "nest of worms" scrotal mass

Only evident in standing position

618

Hydrocele

Collection of serous fluid causes painless scrotal swelling

easily recognized by transillumination

619

Phimosis

Foreskin cannot be pulled back to expose the glans

620

Scrotal pain and loss of cremasteric reflex

Testicular torsion

Emergency!

621

Cryptorchidism

Testicle located in inguinal canal or abdomen

Standard: wait until 1 year of age for intervention

622

ART initiation in tx-naive pts to reduce risk of disease progression

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)

623

ART initiation in tx-naive pts to prevent transmission

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

624

Acute bronchitis pathogens

M. pneumo

C. pneumo

B. pertussis

Not Strep pneumo!

625

intranasal corticosteroid for AR onset of sx relief

few days to a week after starting

626

RSV in AOM

RSV is implicated in causing AOM

627

HIV/AIDs and copper IUD

HIV

2 for initiation and 2 for continuation

AIDS

3 for initiation and 2 continuation

628

Sarcoidosis primary tx

Systemic corticosteroids

629

ARF precipitating factors

Anaphylaxis

Infection

MI

NOT DM1

630

Poikilocytosis define

Alteration in shape of RBCs

631

Most common serious complication of cholecystitis

pancreatitis

632

Fragile X syndrome in males characteristic

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

633

Routine HBV vaccination started in what year

1996

634

HIV screening

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

635

Mood disorder tx goal

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

636

Electroconvulsant therapy (ECT) indication

urgent need for response

pts who are suicidal or refusing food and nutritionally compromised

psychotic sx or catatonia

637

SSRIs

From most to least energizing:

Fluoxetine (Prozac)

Sertraline (Zoloft)

Citalopram (Celexa)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Serotonin = smooths mood

638

SSNRIs

SSNRI

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

desvenlafaxine (Pristiq)

Norepinephrine = Focus

Occassional reports of being energizing, helpful in anxious and/or resistant depression

SNRI - Strattera (ADHD)

639

SDRI

Selective Dopamine Reuptake Inhibitor

Bupropion (Wellbutrin)

Potentially activating, usually used as add-on tx w/ SSRI

640

Antidepressants and suicidality

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

641

Anxiolytics

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

642

Antidepressant sexual adverse effects

SSRI and SNRI = 40%

SDRI = 20%

Anorgasmia, ED, impaired libido

643

SSRI w/ most anticholinergic effect

Avoid in gero

Paroxetine (Paxil)

Increase in constipation, dry mouth, confusion in gero

644

SSRI w/ most drug-drug

Long half-life

Avoid in gero

Fluoxetine (Prozac)

Half life 82 hours, metabolite = 7-15 days

CYP450 Isoenzyme inhibition

One of the oldest in the market

645

SSRI assoc. w/ QT prolongation

Max dose in gero 20 mg/day

Citalopram (Celexa)

QT prolongation risk increased w/ increased dose

646

SSRIs ordered from least drug-drug to most

(CYP450 isonenzyme inhibition)

Preferred in polypharm = first in list

Escitaloporam (Lexapro)

Citalopram (Celexa)

Sertraline (Zoloft)

-

Paroxetine (Paxil)

Fluoxetine (Prozac)

647

TCA associated w/ what adverse effect

TCAs = cardiac and neurotoxic

May cause cardiac dysrhythmias and seizures

 

648

SSRI common issues

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

649

Trust vs mistrust

Erikson

Infant 0-1 year

Task: reliable caregiver

Pathologic outcomes: depression, substance abuse, psychosis

650

Autonomy vs shame and doubt

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

651

Initiative vs guilt

Erikson

Preschool 3-6 years

Task: ability to do things on his/her own

Pathologic outcomes: Conversion disorder, phobia, psychosomatic disorder

652

Industry vs inferiority

Erikson

School age

6-11 years

Task: self-worth, compared to others

Pathologic outcomes: creative inhibition, inertia

653

Identity vs role confusion

Adolescent

12-20 years

Task: who am I

Pathologic outcome: delinquent behavior, gender identity issues, borderline personality disorder, psychotic episodes

654

Intimacy vs Isolation

Young adult hood

21-40 years

Task: forming loving relationships

Pathologic outcomes: schizoid personality disorder

655

Generative lifestyle vs stagnation/self absorption

 

40-60 years

Task: accept self, establish and guide next generation

Pathologic outcome: mid-life crisis

656

Ego integrity vs despair

65 years and older

Task: sense of accomplishment/integrity

Pathologic outcome: extreme alienation, despair

657

Delirium

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

658

Dementia

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

659

Delirium etiology

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)

660

Delirium tx

Treat underlying cause

Infection, medication, and fractures are most common

661

Dementia etiology

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

662

Evaluation of new onset mental status change

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

663

Alzheimer tx - slow decline

Vitamin E 1000 IU BID

OR

Selegiline 5 mg BID

No benefit to using BOTH at the same time

664

Gold standard imaging for PVD

MRA

665

Most potent risk for PVD

Tobacco use

666

Mild to moderate Alzheimers tx

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

667

Moderate to severe Alzheimers tx

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

668

Dementia and depression

40% of pts w/ dementia also have depression

standard antidepressant tx is indicated

keep in mind drug-drug

669

Alzheimer's and antipsychotic

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

670

Zolpidem (Ambien) in gero

Increase fall and fracture risk

671

Nitrofurantoin (Macrobid) in gero

Potential lack of efficacy in impaired renal function of Cr Cl

672

Amitriptyline in gero

TCA

Significant risk of orthostatic hypotension

673

Diclofenac (Voltaren) in gero

(NSAID)

Potential to promote fluid retention
 

674

Sertraline (Zoloft) in gero

Increased risk for hyponatremia

Check electrolytes in 1 month after starting

675

Syncope etiology

Transient loss of consciousness

Vasovagal, cardiac outflow obstruction (hypertrophic cardiomyopathy, valvular, especially high-grade aortic stenosis, aortic dissection, dysrhythmia)

Orthostatic hypotension

676

Typical head growth infant

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

677

CAP hospitalization criteria

No resources for self-care at home

Age 60 and older

PO2 of

RR > 30 breaths

678

Pts with CHF refer to cardio

Pediatric pts

Pregnant women

Lactating women

 

679

Myoclonic seizure

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

680

Waddell sign

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

 

681

Myocardial ischemia ECG

inverted T wave and T wave depression

682

Myocardial injury ECG

ST elevation w/ tall peaked T wave

683

Myocardial infarction ECG

pathologic Q wave

684

Carbamazepine and OCPs

Carbamazepine induces estrogen metabolism = OCP failure

685

Pump and dump

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)

686

Mitral regurgitation

HIGH-pitched, pansystolic murmur heard best at apex

radiates to axilla

Loid-blowing

Use diaphragm of stethoscope

687

Course of bacterial conjunctivitis

with treatment 2-5 days

without treatment 5-7 days

688

Complete resolution of sx in Osgood-Schlatter disease

through physiologic healing

takes 12-24 months

689

Typical physiologic changes during pregnancy

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%

690

Oral iron therapy drug interactions

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

691

SSRI dosages

Prozac 20-80 mg daily

Zoloft 50-200 mg daily

Celexa 40-60 mg daily

Lexapro: 10-20 mg daily

692

Systolic CHF - which drug

ACEIs decrease mortality and prolong survival in clients w/ CHF

Prescribe for all pts with systolic dysfunction unless contraindicated

693

Primary tx for dysmenorrhea

NSAIDs

Oral contraceptives

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

694

Normal WBC count in urine

695

Stage I Lyme

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)

696

Stage II Lyme

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)

 

697

Stage III Lyme

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

698

PAD

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

699

Venous insufficiency

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)

700

Peripheral neuropathy

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

701

Vertical diplopia results from damage to which cranial nerves?

CN III or IV

702

Horizontal diplopia is suggestive of damage to which cranial nerves?

CN III or VI

703

Myrdriasis

Dilation of the pupils

704

Miosis 

Constriction of the pupils

705

When do ovaries become nonpalpable

3-5 years after menopause

706

Acholic stools

Clay or putty colored

Occur briefly in viral hepatitis but are more common w/ obstructive jaundice

707

How long after Syphilis exposure do sx appear?

10 days to 3 months after pathogen exposure primary sx appear

708

Rectal exam: tender, purulent, reddened mass

anal abscess

esp. w/ fever and chills

709

CN involved in closing mouth

CN V

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

710

thick curved extension of the superior border of the scapula

coracoid process

711

Axiohumeral group of muscles produce what movement

internal rotation of shoulders

712

Posterior and medial surface of the knee swelling is suggestive of

Semimembranous bursitis

713

Swelling 1-2 inches below the knee joint on the medial surface is suggestive of

anserine bursitis

714

swelling over the tibial tubercle is suggestive of

infrapatellar bursitis

715

swelling over the patella suggests

prepatellar bursitis

716

Housemaid's knee from excessive kneeling

prepatellar bursitis

717

Ankle reflexes level nerve root

S1

718

Patellar reflex nerve root

L 2, 3, 4

719

Supinator and biceps reflex nerve root

C5 and C6

720

Triceps reflex nerve root

C6 and C7

721

Average incubation period for meningococcal infection

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

722

Thrombosed external hemorrhoid tx

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

723

Most common presenting sign of bladder cancer

Gross painless hematuria

Mircroscopic hematuria in about 20%

Irritative voiding sx occassionally

Abnormal abd mass only w/ advanced disease

724

Post renal azotemia

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

725

Low back pain 

Cauda equina syndrome s/sx

Bladder dysfunction, perineal sensory loss, anal laxity

Neurological deficit in lower extremities

Lower extremity motor weakness

726

Grand mal seizures

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

727

Lung cancer screening

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

728

Chancroid organism

Haemophilus ducreyi

729

Mild cognitive impairment

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

730

Alzheimer's dementia

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

731

Vascular dementia

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

732

Lewy Body dementia (DLB)

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

733

Frontotemporal dementias (FTDs)

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

734

Gout etiology and uric acid

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

735

McMurray Test

Tests for meniscal tear

736

Talar Tilt

Tests for ankle instability

737

Tinel's sign

tests for carpal tunnel

738

Phalen's sign

tests for carpal tunnel

739

Lachman Test

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.

740

Straight leg raise

Tests for lumbar nerve root compression

741

Spurling's Test

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.

742

Drop-arm test

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

743

Empty can test or Jobes test

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.

744

Finkelstein test

DeQuervain's tenosynovitis

745

Polymyalgia Rheumatica and GCA

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

 

746

Polymayalgia Rheumatica Tx

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

747

Spinal Stenosis 

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

748

Reactive arthritis

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

749

Osgood-Schlatter

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

750

Prepatellar bursitis

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

 

751

Meniscal tear

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

752

lumbar-sacral strain

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

753

Lumbar radiculopathy

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

754

What nerve root

Foot dorsiflexion

Knee jerk reflex

medial calf sensation

L4

755

What nerve root

Great toe dorsiflexion

Medial foot sensation

L5

756

What nerve root 

Foot eversion

Ankle jerk reflex

Lateral foot sensation

S1

757

Osteoporosis

BMD -2.5 SD or below

If fractures, deemed severe or "established" osteoporosis

758

Osteopenia

BMD -1.0 to -2.5

759

BMD testing

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)

760

Osteoporosis Tx

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

761

Calcium sources

Dairy and nondairy

Spinach

sardines

tofu

almonds

762

OA dx

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

763

Early-term

37-38 weeks plus 6 days

sleepy baby

wake to feed every 2 hours

764

Full-term baby

39 weeks to 40 weeks plus 6 days

765

Late term baby

41 weeks to 41 weeks and 6 days

Wide awake baby

766

Post-term baby

42 weeks and beyond

Induction considered at 41 to 42 weeks

767

Newborn feeding

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

768

Infant feeding 2 months

Formula: 4-5 oz every 2-4 hours

Breastfeeding: 7-9x/day, dictated by infant

769

Infant feeding 4 months

Formula: 4-6 oz every 3-4 hrs

Breastfeeding: 6-8x/day, dictated by infant and if supplemental feedings

770

Infant feeding 6 months

Formula: 6-8 oz every 4-5 hours

Breastfeeding: 4-6x/day, dictated by infant, supplemental feedings

771

Solids and infant feeding

May start 4-6 months

Solids not really needed until 1 year of age

772

Newborn teaching

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

773

2 months

Can lift self up on 2 arms from tummy

Responds 2 sounds

Smiles when smiled 2

774

4 months

Reaches 4 a toy or other object

Smiles 4 fun

Rolls from tummy to back

775

6 months

Looks like number 6 when sitting up

Rolls from back to tummy and back

776

8 months

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

777

12 months

Stands tall like the number 1 and walks on 2 legs

778

18 months

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

779

2 years

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

780

3 years

Rides a TRIcycle

Build a 3 block tower w/ ease

Can draw a circle

Speaks in 3 word sentences

781

4 years

Speaks in 4 word sentences

Can build a 4 block tower w/ ease

Can draw a cross

782

5 years

Speaks in 5 word sentences

Can draw a square

783

6 years

Can draw a triangle

Speak in 6 word sentences

784

Tooth eruption

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

785

Physiologic galactorrhea

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

786

Foreskin retraction in children

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

787

Communicating hydrocele

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

788

Hernia incarceration/strangulation s/sx

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

789

Non-communicating hydrocele

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

790

Correct latch-on

Mouth covers areola

Lips are flanged out

no dimpling of the baby's cheeks

No clicking sound w/ sucking

791

newborn jaundice

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

792

Pyloric stenosis

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

793

Intussusception

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

794

Time Out

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

795

Percentage of speech intelligible by people not in daily contact with 3.5 y/o child

nearly 100%

796

What age?

Able to verbalize what to do when cold, hungry, tired

Can draw person w/ no torso

Knows first and last name

4.5 year old

Simple abstract problem solving

797

What vaccine, most likely mild fever of 1-2 days in a 6 month old

Pneumococcal conjucate 13-valent (PCV13)

798

When to screen for autism per AAP

18 months and 24 months

(formal screening)

799

Infant born to HBs-Ag positive mother

Give hep B immunization and hep B immuneglobulin to newborn

800

Developmental Red Flags

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

801

Most important time to screen for hearing defects

First days of life

802

Down Syndrome features

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%

803

Car seat rear-facing

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

804

Car-seat for toddlers/preschooler

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

805

School-aged children car seat

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)

806

Older children and seat belts

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

807

Tanner Stages summary

Tanner 1 - pre-pubescent

Tanner 2 - earliest stages

Tanner 3 - growth spurt

Tanner 4 - peak of growth spurt

Tanner 5 - Adult

808

Tanner 2 to Menarche

2 years

Tanner 4 - menarche

809

Tanner 1 

pre- puberty

810

Tanner 2

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

811

Tanner 3

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

812

Tanner 4

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

813

Tanner 5

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

814

1st menses to full adult height in females

1 year

815

Breast budding to full adult height in females

3 years 

816

Tanner 2 to full adult height in males

4 years

817

Puberty

Physical changes leading to sexual maturation and reproductive capability

Puberty occurs during, but is not synonymous with, adolescense

818

Gynecomastia

Usually found in Tanner Stage 3

Usually resolves in 6-12 months

819

Fragile X Syndrome

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 

820

Klinefelter Syndrome

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

821

Turner Syndrome

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

822

Acne Vulgaris pathophys

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

823

Benzoyl Peroxide

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%

824

Tretinoin (retinoic acid) gel, cream

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

825

Topical abx for acne

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

826

Oral abx or acne

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

827

COC for acne

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

828

Isotretinoin (Accutane)

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

829

Mild Acne

Tx:

Topical retinoid alone often helpful

Consider adding topical abx or benzoyl peroxide

830

Moderate acne

20-100 comedones

15-50 inflammatory lesions

30-125 total lesions

Tx: 

Oral abx with topical retinoid

831

Severe acne

> 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

832

Most common cause of adolescent death in US

Accidental injury

833

CRAFFT screening test

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

834

Most common contraceptive used by teens 

Male condom

18% failure rate

835

All 50 states entitle adolescents to conset to care for which conditions?

Contraception

Pregnancy

STI

Substance abuse

Mental health

836

Screening for Type II DM in Children

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

837

Lipid Screening and CV Health in children

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

838

Scarlatina-form or sandpaper rash

Exudative pharyngitis

Fever, headache

tender anterior cervical lymphadenopathy

Rash erupts on day 2 of pharyngitis and often peels a few days later

Dx?

Scarlet fever

Pathogen: S. pyogenes (GABHS)

Tx:

Penicillin first line

PCN allergy: Azithro, clarithro, erithro

839

Discrete rosy-pink macular or maculopapular rash lasting hours to 3 days

Follows a 3-7 days period of fever, often quite high

90% in children

Roseola

Agent: Human herpesvirus 6 (HHV-6)

Often in children 6-24 months

Febrile seizures in 10% of children affected

Supported tx

840

Mild sx

Fever, sore throat, malaise, nasal discharge

Diffuse maculopapular rash lasting 3 days

Posterior cervical and postauricular lymphadenopathy beginning at 5-10 days PRIOR to onset of rash

Arthralgia in 25% (most common in women)

Dx

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

841

Usually acute presentation w/ fever, nasal discharge, cough, generalized lymphadenopathy, conjunctivitis (copious clear discharge), photophobia

Koplik spots appearing 2 days prior to onset of rash as white spots w/ blue rings help within red spots in oral mucose in 1/3 of pts

Pharyngitis mild w/o exudate

Maculopapular rash onset 3-4 days after onset of sx

May coalesce to generalized erythema

Dx

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

842

Maculopapular rash in 20%, rare petechial

Fever, "shaggy" purple-white exudative pharyngitis

Malaise, marked diffuse lymphadenopathy

Hepatic and splenic tenderness w/ occassional enlargement

Dx?

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

843

Fever, malaise, sore mouth, anorexia

1-2 days later, lesions

Also can cause conjunctivitis, pharyngitis

Duration of illness 2-7 days

Dx?

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

844

3-4 days of mild, flu-like illness

Followed by 7-10 days of red rash that begins on face with "slapped cheek" appearance

Spreads to trunk and extremities

 

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

845

Child w/

Maculopapular rash, fever, mild pharyngitis

Ulcerating oral lesions

Diarrhea

Diffuse lymphadenopathy

Dx

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

846

Acute-phase usually lasts 11 days

Fever T > 104 F (40 C) lasting 5 or more days

Polymorphic exanthem on trunk, flexor regions, and perineum

Erythema of oral cavity ("strawberry tongue") w/ extensively chapped lips

Bilateral conjunctivitis usually w/o eye discharge

Cervical lymphadenopathy

Edema and erythema of hands and feet w/ peeling skin (late finding, usually 1-2 weeks after onset of fever)

Dx?

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

847

Most common anemia in childhood