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Flashcards in MidTerm #1 Deck (38):
1

Primary Headaches: Episodic

  • Tension Headache
  • Migraine Headache
  • Sinus Headache
  • Rebound Headache (chronic daily headache)

2

Secondary Headaches

  • Head Trauma
  • Vascular deficit (aneurysm, bleed, etc.)
  • Substance Abuse
  • Infection (meningitis)

3

Don't treat a headache that...

 

  • Severe, "worst of my life"
  • Going on for longer than 10 days
  • Pregnancy, especially 3rd trimester
    • could be sign of preeclampsia 
  • Kids
  • Infection, fever, secondary HA's 
  • ETOH abuse, caution with acetaminophen 
    • can use, just dose appropriately 
  • Non-diagnosed migraine 

4

Tension Headache

  • Symptoms
    • myofascial pain (muscle pain)
    • bilateral
    • diffuse
    • radiating
    • tight
    • pressing
    • cap's too small 
    • Duration: minutes to days
    • Onset: gradual 
  • Secondary to:
    • Stress
    • Anxiety
    • Depression
    • Emotional Conflicts
    • Fatigue 
  • More in women than in men 
  • Treat with APAP, NSAIDs, salicylates
    • Right when starts
  • Physical therapy and relaxation exercise

5

Migraine

  • Complex interaction of neuronal/vascular systems
  • Symptoms:
    • With or without aura 
      • wavy/flashing lights
    • Unilateral/bilateral
    • Throbbing
    • Hours-Days 
  • Lots of triggers
  • Rx:
    • Abortive: triptans, aspirin/caffeine, ergots 
      • for now and again headache
    • Prophylactic: TCA's (tricyclic antidepressant), ß-blocker, CCB (calcium channel blocker), etc.
      • more frequent
    • Symptomatic: Aspirin, APAP, NSAIDs, opiates, sedatives, anti-emetics
      • Need medical diagnosis before treating
      • Avoid giving shot of morphine
      • Go to bed and lie down 
      • Treat at early onset
  • ​Non-Pharmacologic
    • Sleep, nutrition, cope with stress
    • Avoid Mg supplements, nitrates, tyramin, phenylalanine, MSG, caffiene 

6

Sinus Headaches

  • Nasal passageway and sinus opening swelling/obstruction due to trauma, allergies, infection 
  • Location
    • Face, forehead, periorbital area
  • Due to trauma, allergies, sinus infection
  • Pseudoephedrine works best to relieve this headache

7

Rebound Headache

  • AKA: Chronic Daily Headache
    • Occurs after 3 mo. of analgesic use (any analgesic)
    • Notice in the morning > rest of day 
  • Tapered decrease in analgesic use
    • Small dose of tricyclic so they sleep well at night and get over it

8

Lower Back Pain

Goals of Therapy

  • Decrease pain and discomfort
  • Prevent ongoing damage
  • Don't do any harm
  • Get back to normal routines 
    • Back pain from out of shape
      • Don't let them just lie around

9

Lower Back Pain: Exclusions

  • Chronic (>2 weeks)
  • 3rd trimester of pregnancy
  • Kids <7 yo
  • Fever/infection
  • Numbness/Tingly
  • Loss of bowel/bladder function
    • need to elimate spinal cord injury
    • Limited time to deocmpress w/o permanent damage
  • Severe pain
  • Pain that continues 10 days after treatment
  • Increased intensity or change in character
  • Pelvic/Abdominal pain
  • Visually deformed joint, abnormal movement, weakness in limb, suspected fracture 

10

Lower Back Pain: Red Flags

  • Numbness/Tingling
  • Referred pain from internal organs
  • Cancer: weight loss; over 50 yo/under 16yrs; night pain or at rest; failure to improve; persists>6 weeks
  • Infection Related: Fever, IVDA (intravenous drug abuser), recent infection, immunocopromised 
  • Cauda Equina Syndrome:
    • Note: waiting >72 hours to decompress risks permanent neurological deficit 
  • Vertebral Fracture: Steroids, mild trauma at >50yo, >70 yo, osteoporosis, significant trauma 
  • Acute Abdominal Aortic Aneurism: abdominal pulsating mass, ASCVD (ateriosclerotic cardiovascular disease), pain at rest or noctural pain, >60 yo, smoker

11

Pain Types

  • Acute Pain:
    • Pain that comes on quickly, can be sever, bust lasts a relatively short time
  • Chronic Malignant Pain:
    • Associated with advanced, progressive disease (often fatal) such as cancer, MS, AIDS, and terminal kidney disease  
  • Chronic Non-Malignant:
    • Begins as acute pain, but it continues beyond the typical time expected for resolution of the problem or persists, or reocurrs for other reasons

12

Lower Back Pain: Treatment

  • RICE
    • rest, ice, compression, elevation
    • Ice 10 min 3-4x daily 
  • NICE
    • NSAIDs, ice compression, elevation 
  • Step Approach (adjuncts):
    • NSAIDs, capsaicin, anesthetics, TCA, gabapentin, opiates
  • Topical methyl salicylate 10% (counter irritant)
  • Capsaicin takes 1+ weeks to begin working

13

Osteoarthritis vs. Rhumatoid Arthritis 

  • Osteoarthritis:
    • Dull pain, stiffness in knees, hips, spine, hands, weight-bearing joints, and typically uni-lateral (can be bilateral)
  • Rheumatoid Arthritis:
    • Swollen, tender, warm , symmetrical pain in hands, wrists, fingers
    • Aggravated by movement
    • Worse in the morning 
    • Needs prescription
    • Psoriasis has arthritis associated 

14

Joint Pain: Self-Treatment Exclusions

Same as those in backpain:

  • Chronic (>2 weeks)
  • 3rd trimester of pregnancy
  • Kids <7 yo
  • Fever/infection
  • Severe pain
  • Pain that continues 10 days after treatment
  • Increased intensity or change in character
  • Pelvic/Abdominal pain
  • Visually deformed joint, abnormal movement, weakness in limb, suspected fracture 

15

Joint Pain: Treatment 

  • APAP
  • Topical analgesic
    • Casaicin: take over a week to begin working
    • Topical methyl salicylate 10%: possible counter irritant but immediate effect
  • NSAID (only when inflammation is present, prostaglandins needed for healing too)
  • Glucosamine
    • Very safe, placebo effect
    • Kills pancreatic cells,  increasing risk of developing diabetes
  • SAM-e
    • very safe, may be helpful
    • less joint space narrowing 

16

Tennis Elbow (Tendonitis)

  • Symptoms:
    • warm, swollen, red , tender, pain with extension 
  • Nonpharmacologic Treatment
    • Palm-up lifting-No
    • Forearm Band
    • RICE, NICE won't be effective
  • Pharmacologic Treatment
    • Ibuprofen, but need Rx dose
    • Topical Analgesic 

17

NSAIDs and inflammatory disease or acute muscle injury

  • NSAIDs may be preferred for self treatment
  • Aspirin must be dosed near the self-care max in order to achieve anti-inflammatory response
  • Recommend naproxen to treat swelling and pain, acetaminophen will only treat pain

18

Fever: Symptoms

  • Temporal greater than 100.1
  • Oral greater than 99,7
  • Add one degree to oral temperature to get rectal/tympanic temperature
  • Subtract one degree from oral temperature to get axillary temperature
  • axiallary>oral>rectal/tympanic
  • Don't Treat Numbers 

19

Fever: Self-Treatment Exclusions

  • ​>6 month and 1040
  • <6 month and 1010
  • Systemic Infection
  • Hyperthermia risk
  • Impaired oxygen utilization (COPD, resp. distress, heart failure)
  • Immpaired Immune function (cancer, HIV)
  • CNS damage (head trauma, stroke)
  • Children with history of febrile seizures/seizures
    • Be more aggresive at treating in order to avoid and have a full work up done 
  • Children who are vomitting/cannot keep down fluids and are very sleep/irritable/hard to wake up

20

Fever: Non-Pharmacologic Treatment

  • Adequate fluids to prevent dehydration 
  • Wear light clothing
  • Remove blankets
  • Maintain room temperature at 680F
  • Increase fluid uptake 50-100 mL/hr 

21

APAP dosing/info

  • Acetaminophen
    • Tylenol
    • Works in CNS, pain & fever
    • NOT anti-inflammatory
  • Child
    • 10-15 mg/kg q4-6h 
    • Not to exceed 5 dose in 24 hours
  • Adult
    • 325-1000 mg q4-6h
    • Max 3000 mg
    • ​With moderate drinking, max 1500 mg
      • Male <2 a day 
      • Female <1 a day
  • ​Cautions:
    • Liver damage
    • Analgesic of choice for warfarin patients 
    • Best for pregnant women 
    • Best for elderly and those with hypertension

22

NSAIDS dosing/information

  • Naproxen (Aleve), Ibuprofen (Advil, Motrin)
    • Peripheral COX inhibitors
    • Pain, fever, high doses for swelling
  • Ibuprofen: 
    • Child: 5-10 mg/kg q6-8h, not to exceed 4 dose in one day
    • Adult: 200-400 mg q4-6h (1200 mg max)
  • Naproxen:
    • Child not recomended for children less than 12
    • Adult: 220 mg q8-12h (660mg max)
  • Ibuprofen slightly better for fever...not much difference
  • Don't use if history of ulcer/GI bleed
  • Avoid with Gout
  • Caution: risk for heart failure, hypertension and stroke.
  • Asthma, Nasal polyps, aspirin allergy->AVOID

23

Asprin Dosing

  • COX inhibitor
  • GI ulcer, HBP, CHF, kidney disease, gout, avoid
  • Avoid in pregnancy
  • Reye's Syndrome 
    • Children under 15 
  • Fever, aches and pains
  • Asthma, nasal polyps
  • Dosing:
    • Children: Not recomended
    • Adult: 650-1000mg q4-6h (4000mg)

24

Douching

  • NOT GOOD
  • black, little education, incarcerated adolescents
    • Increased risk of PID, reduced fertility, ectopic pregnancy, vaginal infections, STI, low birthweight infants, cervical cancer
  • irritation
  • disrupt normal flora and pH
  • Tactfully discourage

25

Atrophic Vaginits

  • Symptoms:
    • dyspareunia, lack of adequate vaginal lube
    • irritation, dryness, burning, itching, leuokrrhea (milky white discharge)
    • Incontinence in older 
  • Cause
    • Low estrogen levels
  • Treatment:
    • Lubicrant products
      • water soluable
    • Sexual activity 
    • Dryness: estrogen 
      • unopposed estrogen associated with endometrial cancer
      • vaginal estrogen very well absorbed
  • Exclusions:
    • postmenopausal bleeding
      • especially if bleeding and on estrogen
    • Not relieved by lubricants
    • Symptoms that are not localized
    • Severe vaginal dryness or dyspareunia

26

PMS

  • Behavioral: fatigue, irritable, depression, etc.
  • Physical: bloating, breast tender, acne, appetite changes, headache
  • Sign: bad before period and goes away with start of menses
    • Very dramatic, may be PMDD, need referral
  • Treatment:
    • Charting
      • mark days of symptoms and days of period
    • Education, diet modification, exercise, stress managment
    • Vitamin B6 and Calcium and Vitmain D
      • Mood 
      • B=100mg, C and D=1000mg
    • Vitamin E
      • Breast tenderness'
    • NSAIDs
      • Headache
    • Midol and Pamprin is a bunch of crap
      • diuretics don't work 

27

Dysmenorrhea

  • Primary: associated with cramp-like abdominal pain without pelic disease
    • within 6-12 months of menarche
    • less likely after 25 yo
    • Severe pain, miss school 
  • Secondary: associated with pelvic pathology 
    • IUD can cause
    • Secondary needs a cause/source
  • Primary Clinical Presentation:
    • Dull pain and cramping
    • N/V/D
    • irritability and headache
    • at the start of menses 
  • Non-Pharmacological Therapy
    • Heat, exercise, massage, sleep
    • Omega-3-FA
  • Pharmacological Therapy
    • Not aspirin or acetaminophen due to Reyes and CNS
    • NSAIDs
      • prostaglandins have a short half-life, so can work at onset
    • perhaps oral contraceptive pilll 

28

Vulvocaginal Candidiasis (yeast)

  • Classic Symptoms:
    • Thick, white "cottage cheese", no odor discharge
    • Normal pH
    • redness, itching, swelling
    • might be from immunosuppresant or antibiotics
  • Treatment
    • not treat partner
  • Non-pharmacological
    • Decrease refined sugar, eat yogurt
  • Pharmacological
    • Avoid 1 day treatments
    • Should improve within 2-3 days 
    • If itch, use cream 
    • miconazole, clotrimazole, butoconazole, tioconozole
      • nystatin=yeast only=not good choice
      • fluconazole=last a long time in the body
        • may need to use another course if on antibiotics
  • Drug interactions
    • warfarin and miconazole
    • warfarin and flucanazole 
  • Exclusions:
    • Preganancy
    • Girls less than 12 yo
    • fever and lower belly pain
    • uncontrolled/undiagnosed diabetes, HIV infection
    • recurrent (>3 VVC/year or within the past 2 months)

29

Bacterial Vaginosis: BV

  • Symptoms:
    • thin, water discharge
    • off-white or discolored
    • fishy smell
    • irritation
    • dysuria
    • itch
  • Risk Factors:
    • new partner, IUD, smoking
  • Treatment:
    • Requires referral
    • No treatment of partner
    • change in normal flora, not necissarily an STD
    • Common

30

Trichomoniasis 

  • Symptoms
    • Smelly, yellow-green discharge
    • Pruritius
    • Erythema
    • Edema
  • Risk Factor:
    • Multiple Sex partner, new sex partner, unprotected sex, other STI
  • Treatment
    • Require referral, reportable disease 
    • Treat partner
    • Tinadazole

31

Toxic Shock Syndrome (TSS)

  • Symptoms:
    • Red rash on palms
    • low blood pressure
    • cramps
    • nausea
    • dizziness
      • Day 2-3: fever, vomitting, dizziness 
  • Within 2 days of menses, using super absorbant tampons

32

Allergic Rhinitis

  • Signs and Symptoms
    • Watery eyes; itchy nose, eyes or throat, sneezing, nasal congestion, runny nose
  • Best is avoidance
  • Nasal saline irrigation, HEPA filter
  • Recommended OTC
    • Antihistamines 
      • 1st generation: benadryl (diphenhydramine)
        • sedative, 
      • 2nd generation, claratin (loratidine), allegra (fexofenadine), zyrtec (cetirizine)
        • non-sedative
        • weak, good for mild allgery
    • Inhaled corticosteroids
      • Flonase (fluticasone) and triamcinaclone
      • when taking this, don't need antihistamine
  • ​Exclusions:
    • Signs of otitis media, sinusitis, lower respiratory problems
    • history of non-allergic rhinitis
    • narrow-angle glaucoma
    • <12 yo
    • pregnant or lactating 
  • Other Info:
    • Only treat most prevalent
    • itch: require sedating antihistamine, can use zyrtec due to minial sedation

33

Cold 

  • Signs and Symptoms:
    • Sore throat, nasal congestion, runny nose, sneezing, low fever, chills, headache, possble cough
  • Exclusions
    • Fever >101.5
    • Chest pain
    • Sign of bacterial infection
    • COPD
    • Not improve in 7 days
    • AID/Immunosuppresed
    • Infant <2 yo
    • Frail/elderly 
  • Nonpharmacologic:
    • fluid, rest, toilet
    • Echinacea at the 1st signs/symptoms
  • Recommended OTC:
    • Jolly ranchers
      • instead of local anesthic like benzocaine
    • Decongestant:
      • pseudophedrine, (systemic) oxymetazoline (LA), ephedrine, pheylephrine (topical)
        • AVOID selling phenylephrine (systemic), degraded in liver and not reach nose (ex: sudafed-PE)
    • Antitussive:
      • dextromethorphan: 6-8 hrs, not constipative, not sedative
      • codeine: 4-6 hour, constipative, sedative, use for sleep
      • (benzonatate (Tessalon perle))
    • Expectorants:
      • Guanisefen: witchcraft
    • Analgesics
      • Not aspirin 
  • ​​Other Notes
    • No cold preps for kids under 4
    • Honey works such as well to soothe throats
    • Treat symptoms as they come instead of using combo products
    • Echinacea not for those on immunosuppressants 

34

Influenza

  • Signs and Symptoms
    • Aches and Pains, myalgia
    • Fever
    • Sore Throat, cough, fatigue
  • Use same method as cold

35

Rhinitis Medicamentosa (Rebound Congestion)

  • Signs and Symptoms:
    • Stuffy nose due to overuse of decongestants
  • Treatments
    • Quit cold turkey
    • Leversee method
      • one nostril at a time
    • Long-Term: use steroidal nasal spray for allergies 

36

Asthma 

  • Signs and Symptoms
    • Wheezy, cough, shortness of breath
    • cough could be only symptom
  • Don't sell primatene mist or tablets
  • Refer for MDI

37

Cough

  • Exclusions
    • Fever>101.5
    • history of underlying disease associated with cough
      • COPD, chronic bronchitis, CHF​
    • Suspected drug associated cough
    • cough>7 days
    • uninteded weight loss
    • drenching nighttime sweats
  • OTC
    • codeine 10-20 mg q4h
      • constipative, sedative
    • dextromethorphan 10-20 mg q4h

38

Strep Throat Considerations

  • Must have at least two of the three:
    1. ​Sore Throat
    2. Tender Lymph Node
    3. Pus on tonsils
  • If there is a cough, then NOT strep
  • 1 to 2 year olds don't get strep
  • May be associated with fever