You have been treating Jason, 35 y/o M, for HIV infection, and the course of his treatment requires that he be hospitalized for a few days. His medical bill is paid by his Aunt, Sylvia, who wants to know why her nephew was in the hospital, but Jason is not willing to share that information. What is the appropriate course of action?
the NP should not release the details of Jason’s health status to his aunt
Which of the following best describes a II/VI heart murmur?
Audible but faint
21 y/o M comes complaining of a painful bump with small, red-looking halo on his penis. The affected area is about 5 mm in diameter, soft and TTT. he states that the halo has been there for about a week and is painful. he doubts that he has a STI, since the only unprotected sex he has ever had has been with his current, longtime GF. he adds that his GF “can be trusted” and that she has never had an STI. What is the most likely diagnosis?
Chancroid
While treating 29 y/o F for vulvovaginitis, you inquire about her sexual hx. She explains that she has been sexually active for about 10 years. There are many cases of vulvovaginitis, but only one is an STI. Which one?
Trichomoniasis
35 y/o sarah says she her partner are in committed relationship and are looking for long lasting, effortless BC method. She wants to explore her BC options but mentions that she has an allergy to estrogen=based BC. What choice should be recommended?
Implanon
Differences b/t glaucoma and cataracts. Which test would be test?
T test
Which of the following CN does NOT control eye movement
CN II (Olfatory)
A man who recently attempted suicide is brought to your office by his wife. Having conducted a significant amount of research on her own about suicide prevention, she has many questions. Which of the following choice is the LEAST effective treatment for her husband?
? Intervention is the pt’s risk is escalating
During a physical exam, Brett mentions that he wants to quit his job but is worried about losing health insurance. you inform him that HIPAA will provide protection for workers when they change or lose their jobs. This includes certain private information that pertains to Brett’s experience with the healthcare system. What is NOT true about HIPAA?
? All sharing of pt’s information requires written authorization
Using the Dubowitz/Ballard exam to estimate the gestational age of a Caucasian newborn, you determine him to be post-term. Which of the following is a finding NOT related to a criterion included in the Dubowitz/Ballard exam?
Elasticity of cartilage in nose
plantar creases over sole of feet
thickness and size of breast tissue
Hypertonic flexion of knees are included
There is concern at your clinic that some children with developmental delays are not being identified soon enough. You are examining a 6 y/o M. Which is the best tool to identify risk for developmental delay in this child?
Denver II
Doris, 77 y/o F, reports abd pain in the LLQ. For the last several weeks, Doris experienced frequent constipation and has taken laxatives for relief. However, her abd pain has become increasing severe and has been accompanied by n/v. Her lab work shows an ESR of 45 mm/hour and leukocytosis. Additionally, a sigmoidoscopy reveals inflamed mucosa. What is the most likely diagnosis?
Diverticulitis
Donna, 25, took pregnancy test a week ago and learned that she is pregnant. Her mother is currently on insulin therapy to control diabetes, and Donna has BMI of 31. Since she is in her first trimester, which of the following diagnostic tests should you first order to assess the risk specific to this pt?
Urinalysis
Kaitlin is 18 y/o and has recently become sexually active. She requests a contraceptive prescription at your clinic. A physical exam indicates that she is 5’6 and 205lbs. Based on her ht and wt, which would be the LEAST effective form of contraception?
? Nuva ring
Tanya is 10 y/o, 4’8, and 110 lbs. Tanya’s mother is concerned about her wt and eating habits, as she has found junk food wrappers hidden around the house. She adds that Tanya is very defiant when it comes to food restrictions. Which of the following is the most appropriate way of approaching the topic of diet with Tanya?
Review the new MyPlate standards with Tanya and help her understand why a balanced diet and maintaining a healthy wt are important
Dori, 64, has experienced recurring bouts of shingles. although you note during todays appointment that her skin eruptions have disappeared, she complains of pain and burning sensations that remain in the areas of outbreak. These sensations, she adds, have been severe enough to interfere with her sleep. What would be prescribed?
Gabapentin
24 y/o comes in for sore throat, nasal congestion, and cough. Pt repeatedly clears her watery congestion into tissue. Pt does not have fever, and PE is unremarkable. What is the most likely cause?
Common cold
59 y/o M is having FU eval 2 years after conclusion of chemo for leukemia. He tells you that he has been feeling “run down” and report unexplained wt loss, pain below the ribs on his left side, and night sweats. You determine he also has a fever. You consider chronic myelogenous leukemia Which finding is hallmark?
? Lymphocytosis
15 y/o penelope, who complains of regularly being tired. You note that she has dry skin, thinning hair, and intolerance to cold. Which of the following should be tested for in order to verify the most likely diagnosis?
? Elevated TSH and decreased T4
65 y/o in recent months noticed persistent, sharp, and painful spasms in her left cheek. They occur primarily when she is applying makeup and do not occur on the other side of her face. The pain feels like “an electric shock”. Which fo the following would be LEAST appropriate treatment for this condition?
Calcium channel blocker
*Anti-seizure drugs
Muscle relaxants
Tricyclic antidepressants
What is the purpose of case mgmt?
To mobilize, monitor, and control resources used by pt during illness
16 y/o M, with no abnormalities in his medical records, presents with unusual body proportions and underdeveloped sexual characteristics. Blood test indicates Klinefelter syndrome. Which is NOT typical feature of klinefelter syndrome?
Short stature
*Hypogonadism
learning disability
Gynecomastia
Elderly have a blunted fever response to infection due to an impairment in which body system?
Nervous system
Prophylactic treatment of Pneumocystis jirovecii
Co-trimoxazole (trimethoprim-sulfamoxazole)
ECG changes in hypokalemia
broad T wave and prominent U waves
Atypical UTI symptoms usually found in elderly pts
lethargy
decreased appetite
incontinence
acidosis and hyperthermia have what affect on the oxyhemoglobin dissociation curve
oxygen has a decreased affinity for hemoglobin shifting the curve to the right + to the tissues
alkalosis and hypothermia have what effect on the oxyhemoglobin dissociation curve
oxygen has a greater affinity for hemoglobin shifting the curve to the left = to the blood
What does it mean when there is a right shift in the oxyhemoglobin dissociation curve?
means that a higher PO2 is required to achieve hemoglobin saturation compared to baseline
*oxygen is more willing to unload into the tissues
What does it mean when there is a left shift in the oxyhemoglobin dissociation curve?
it means that less PO2 is required to achieve hemoglobin saturation compared to baseline
*oxygen is less willing to unload into the tissues
JNC 8 threshold for treatment of HTN in the elderly
150/90
Immediate treatment after diagnosis of pheochromocytoma is what?
Phentolamine to stabilize before surgery
Criteria for diminished renal reserve
nephron loss of 50% and double baseline Cr
Criteria of renal insuficiency
nephron loss of 75% and mild azotemia
Treatment of bacterial vaginosis
metronidazole or clindamycin
End-stage renal disease criteria
90% nephron loss, azotemia, and metabolic alterations
American Burn Association: Burn Center Referral Criteria
- Partial thickness >10% TBSA
Burns that involve the face, hands, feet, genitalia, perineum, or major joints - 3rd degree
- electrical
- chemical
- inhalation injury
- burns with preexisting medical disorders that could complicate
- burn + trauma
- burned children
- burns that will require special social, emotional, or rehabilitation intervention
dislocation
displacement of a bone from its joint
subluxation
partial dislocation
Labs in temporal arteritis
high ESR
normal WBC
Temporal arteritis treatment
High-dose steroids
Normal CVP
2-6
CVP is elevated in conditions that cause a(n) _ in the amount of fluid in the right atrium
increase
Shock states that cause an elevated CVP
cardiogenic shock
obstructive shock
*also FVO
CVP is decreased in conditions that cause a(n) _ in the amount of fluid in the right atria
decrease
Shock states that cause a decreased CVP
distributive shock
hypovolemic shock
MAP formula
(SBP + 2DBP)/3
Normal pulmonary wedge pressure
6-12
Shock states with elevated PWP
cardiogenic
low then high – septic
Shock states that cause low PWP
hypovolemic
obstructive
anaphylactic
neurogenic
PWP is a measure of what
left ventricular function
end-diastolic left ventricular pressure
PWP is increased in conditions that __ the pressure in the left ventricle at the end of diastole
increase
Conditions that increase PWP
FVO
decreased elasticity of the left ventricle
PWP is decreased in conditions that ___ the pressure in the left ventricle at the end of diastole
decrease
Normal CVP
2-6 mmHg
Normal PWCP
6-12 mmHg
Cardiac Output
HR x SV
Normal CO
4-8 L/min
Normal CI
2.5-4
SVR
the resistance of systemic circulation
Normal SVR
800-1200
Where is SvO2 measured?
Pulmonary artery
What is SvO2
a measurement of effectiveness of O2 delivery
Normal SvO2
60-80%
What does low SvO2 indicate
increased tissue extraction of O2
decreased O2 supply (decreased CO, decreased FiO2, anemia)
increased O2 demand (fever, shivering, increased WOB)
What does high SvO2 indicate?
decreased tissue extraction of O2
increased O2 supply (FiO2 > need)
decreased O2 demand (hypothermia)
decreased effectiveness of O2 delivery and uptake by cells (sepsis, shift of oxyhemoglobin dissociation curve to the left)
Hypovolemic shock hemodynamics
SVR HIGH, everything else low
CO/CI – low
CVP – Low
PWP – low
SVR – HIGH
SvO2 – low
Cardiogenic shock hemodynamics
LOW CO/CI & SvO2 everything else high
CO/CI – low
CVP – HIGH
PWP – HIGH
SVR – HIGH
SvO2 – low
septic shock hemodynamics
CO/CI: High then low (only shock state with high CO)
everything else: low then high
Anaphylactic shock hemodynamics
everything low
obstructive shock hemodynamics
LOW CO/CI and normal to low PWCP; everything else HIGH
CO/CI – low
CVP – HIGH
PWP normal/low
SVR – HIGH
SvO2 – HIGH
Neurogenic shock hemodynamics
everything low
Herbal agents that increase risk of bleeding
if it starts with G it increases bleeding
Ginger
Ginko Biloba
Garlic
Ginseng
Herbal agents that increase clotting
St. Jon’s Wart
Use of St. Johns wart
depression
BPH
Sleep
Normal Plts
150,000-400,000/mm3
Lower UTI drugs
trimethoprim-sulfamethoxazole (Bactrim) <20% resistance nitrofurantoin (Macrobid) >20% resistance
Fosfomycin (expensive)
Upper UTI drugs
Ciprofloxacin
Levofloxacin
Ceftriaxone (IV)
Prerenal Diagnostics
Serum BUN:Cr – >10:1
urine Na – <20 mmol SG – >1.015
Fractional Excretion of Na <1
Urinary Sediment – normal/few hyaline casts
Intrarenal diagnostics
Serum BUN:Cr – 10:1
Urine Na – >40 mmol
SG <1.015 Fractional Excretion of Na >3
Urine Sediment Granular with white casts
Postrenal diagnostics
Serum BUN:Cr – 10:1
Urine Na – >40 mmol
SG <1.015 Fractional Excretion of Na – usually >3
Management of Prerenal AKI
expand volume
Management of intrarenal AKI
maintain perfusion, stop nephrotoxic drugs, RRT
Management of post renal AKI
remove obstruction
Criteria of dialysis
A – acidosis (metabolic)
E – electrolyte abnormalities
I – intoxication
O – oliguria <400 cc/day
U – uremia
Most common nephrotoxic drugs
- antifungals (“fungins”, “azoles” and Amphotericin B {amphoterrible})
- aminoglycoside abx (vancomycin, streptomycin, tobramycin, gentamycin)
- NSAIDs
- ACE inhibitors
Differential for testicular pain
renal stone (no relief with testicular lift)
epididymitis (relief with testicular lift)
torsion (no relief with testicular lift)
Management of nephrolithiasis
CT scan
PRN morphine or dilaudid and x1 toradol, and x1 reglan
possible lithotripsy (large stone)
Black box warning for Reglam
EPS – tardive dyskinesia in long term use
BPH onset
50 yo
Use of Saw Palmetto
BPH
no evidence for Prostate Cancer prevention!!
Normal GFR
125 mL/min
GFR diminishes __% per decade after 30yo
10
Normal Renal Gerontology changes
decreased kidney size and number of nephrons
reduced response to vasopressin and impaired Na conservation
decreased bladder tone, elasticity, and capacity
prostate enlargement
GFR formula
(140 – age) x (WT x .85 {for women})/73 x Serum Cr
Which patients do we treat for asymptomatic bacteriuria
pregnancy
urologic interventions
renal transplant
Valve activity in S1
mitral/tricuspid close
aortic/pulmonic open
Valve activity in S2
aortic/pulmonic close
mitral/tricuspid open
S3 heart sound
Increased ventricular filling pressure (e.g., mitral regurgitation, HF), common in dilated ventricles, pregnancy
S4 heart sound
Atrial Gallup;
related to stiffness of the ventricular myocardium to rapid filling
Murmur grades
I/VI – barely audible
II/VI: audible but faint
III/VI: moderately loud
IV/VI: loud with a thrill
V/VI: very loud
VI/VI: loudest
Ms. Ard and Mr. Ass
Mitral Stenosis & Aortic Regurgitation = Diastolic
Mitral regurgitation & Atrial Stenosis = Systolic
Murmur locations
Aortic – Right sternal boarder 2nds ICS
Pulmonic – left sternal boarder 2nd ICS
Tricuspid – left sternal boarder 4th ICS
Mitral – 5th ICS at midclavicular line
NYHA Classification of HF
class 1 -no symptoms
class 2 – slight symptoms on exertion
class 3 – marked symptoms on exertion
class 4 – symptoms at rest
Treatment of acute pulmonary edema
low flow O2
4 morphine
40 mg lasix x2 q10
decreased cortisol levels
-Adrenal hyperplasia
-Addison’s disease
-Anterior pituitary hyposecretion
-Hypothyroidism
increased cortisol levels
-Hyperthyroidism
-cushing’s syndrome
-Stress d/t trauma/surgery
-carcinoma
-Overproduction of ACTH d/t tumors in ant. Pituitary
-Adrenal adenoma
-Obesity
ACC/AHA Stage 1 HTN
130-139 or 80-89
ACC/AHA Stage 2 HTN
140 OR >90
First line HTN medication
thiazide diuretics
Management of HTN urgency
oral meds
clonidine (Catapres)
Treatment of HTN emergency
IV Nicardipine, Nitroprusside or labetalol
decreased 25% first hour
then to 160/100 next 2-6 hr
What is Prinzmetal’s angina?
coronary artery vasospasm
Lipid panel normals
Normal LDL <100 or <70 if DM HDL>40 (M), >50 (F)
and triglycerides <150
Meds for angina
nitrates, beta blockers, calcium channel blockers
What is the Pooled Cohort Equation used for
Est 10 year ASCVD risk
High intensity statins
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
Therapeutic INR
2-3
Therapeutic PTT
1.5-2 x normal or control values
Contraindications for TPA
Neuro surgery/head trauma within 3 months
Prior ICH
BP: >185 or Diastolic >110
Lumbar puncture recently
3 hours
If it is a hemorrhagic stroke
Seizures
Abnormal glucose levels <50 >400
Any known bleeding disorders
Active internal bleeding
Suspected dissection
Malingnant intercranial neoplasmq
Medication management of PVD
Cilostazol (pletal)
Normal ABI
0.9-1.3
ABI indicative of PVD
<1
ECG changes in pericarditis
ST segment elevation and T wave inversion
PR depression
Treatment of pericarditis
NSAIDs
Indomethacin
Corticosteroids if NSAID failure after several wks
ABX – only if bacterial
Major complication of pericarditis
cardiac tamponade
Causes of night sweats in adults
endocarditis
TB
menopause
HIV/AIDS
leukemia
Fever
malaise
night sweats
WT loss
endocarditis
Top fiver killers of adults in US
Heart disease (CAD)
Cancer
Accidents
Lower Respiratory disease (Asthma&COPD)
CVA
Cranial nerves
I: Olfactory, smell, Sensory
II: optic, vision, sensory
III: oculomotor, EOM, motor
IV: trochlear, downward and inward eye movement, motor
V: Trigeminal, mastication, sensation of face, scalp, cornea, and mucous membranes, both
VI: abducens, lateral eye movement, motor
VII: Facial, facial sensation and movement, both
VIII: acoustic, hearing and equilibrium, sensory
IX: Glossopharyngeal, phonation, gag, carotid reflex, swallowing, 1/3 taste, both
X: Vagus, talking, swallow, carotid reflex, both
XI: Spinal Accessory, shoulder and head movement, motor
XII: Hypoglossal, tounge movement, motor
Signs of vertebrobasilar stroke
vertigo, ataxia, dizziness, visual field deficits, wkns, confusion
Potassium considerations in burn pts
monitor for hyperkalemia firs 24-48 hr
monitor for hypokalemia 3 days post burns
How to remove tar in tar burns
petroleum products – ie bacitracin, petroleum jelly
signs of temporal arteritis
Visual LOSS!
Swollen pale disc with blurred margin on eye exam
Jaw claudication
Age over 50
scalp tenderness
fever
Temporal artery nodular or enlarged and tender
Eye cup : disk
1:2
Cause of increased cup size in eye
galucoma
A/V ratio in the eye
2:3 or 4:5, opposite in body, arteries are brighter red and narrower
Signs of diabetic retinopathy
cotton wool spots
ruptured microaneurysm
hard exudates
AV nicking is most commonly seen on retinal exam of which chronic condition?
HTN
Differentiation of Conjunctivitis and treatments
Chemical – none, flush with NS
Bacterial – Purulent, ABX – levofloxacin, ciprofloxacin, moxifloxacin, tobramycin, gentamycin)
Viral – watery – saline drops, decongestants/antihistamines, mast cell stabilizers, NSAIDS
Herpetic – bright red and irritated – refer to opthalmologist
Gonococcal or chlamydial – Copious purulent – Ceftriaxone 250 mg IM + Azithromycin
Gonococcal and chlamydia treatment
Ceftriaxone 250 mg IM + azithromycin
Normal intraocular pressure (IOP)
10-20 mmHg
Treatment of open angle glaucoma
-prostaglandins (lantanoprost, bimatoprost): inc outflow
-beta blockers (timolol, bextalol): dec aqeuous humor production; or
-pilocarpine to inc aqeuous humor outflow
-carbonic anhydrase inhib can work too
-if meds fail, lsaer trabeculoplasty or trabeculectomy
treatment of closed angle glaucoma
-medical emergency! goal: decrease IOP
1: mannitol
-eyedrops: timolol, pilocarpine, apraclonidine
-systemic meds: (oral/IV acetazolamide, IV mannitol)
-curative: Laser peripheral iridotomy (create hole in peripheral iris)
Major differences in acute/closed angle glaucoma and cataract exam
similar presentation except cataracts are painless
Adult Portion
Contraceptive Options
What would cause break through bleeding on Day 1-9 of cycle?
deficiency of estrogen
What would cause break through bleeding on Day 20-21 of cycle
deficiency of progesterone
What are the absolute contraindications of COC?
hx thromboembolic disorders
CVA
CAD
breast CA
estrogen-dep neoplasia
pregnancy
liver tumor; impaired LF
previous cholelithiasis during pregnancy
undiagnosed, abnormal uterine bleeding
What type of pill for migraine HAs, breastfeeding, contraindication to COC?
progestin-only mini pill
When should a diaphragm/cervical cap be refitted?
gain or loss of 20lbs
How long should a diaphragm be left in vagina following intercourse?
6 hours
EENT
If cup is more than 1/2 the size of the disc diameter, consider __
glaucoma
Raised area at where an artery and vein meet
nicking = hypertension
infection of the eye usually by S. aureus
abrupt onset
painful
erythema
localized tender mass in eyelid
hordeolum (stye)
management of hordeolum (stye)
warm compresses
topical bacitracin or erythromycin
beady nodule on eye lid, infection or retention cyst of meibomian glad, usually on upper lid
painless
swelling, tenderness, sensitive to light, increased tearing
chalazion
management of chalazion
warm compresses
refer for surgical removal
Staph infection or seborrheic dermatitis of lid edge
red, scaly, greasy flakes
thickened, crusted lid margins
burning, itching, tearing
blepharitis
management of blepharitis
hot compress
topical bacitracin or erythromycin
scrub lashes and lids
treatment for bacterial conjunctivitis
antibiotic drops- levo, oflo, cipro floxacin, or tobramycin or gentamycin soln
gonorrhea in eye
Ceftriaxone (rocephin) 250 mg IM
chlamydia in eye
1 gm azithromycin
treatment for allergic conjunctivitis
po antihistamines
increased intraocular pressure
glaucoma
type of glaucoma:
-asymptomatic
-incr IOP
-cupping of disc
-decr peripheral vision
open-angle
type of glaucoma:
-extreme pain
-blurred vision
-halos around lights
-pupil dilated or fixed
closed-angle
Tonometry screening nationally recommended by age
40
clouding and opacification of the normally clear lens of the eye
-painless
-clouded, blurred vision
-halos around lights
-night vision difficulty
-sensitivity to light and glare
-fading/yellowing of colors
-diplopia (double vision) in single eye
-no red reflex
cataract
separation of the light-sensitive membrane in the back of the eye (retina) from its supporting layers
-flashes of light (photopsia), esp. peripheral
-floaters in eye
-blurred vision
-shadow or blindness in a part of visual field
retinal detachment
1, #2, #3 causes of otitis, sinusitis, & CAP
- Strep pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
type of chronic otitis media consisting of peeling layers of scaly or keratinized epithelium; if untreated, may erode the middle ear, leading to nerve damage and deafness
squamous epithelium lined sac, filled with desquamated keratin
painless otorrhea, hearing loss, canal filled with mucous and granulation tissue
tympanic membrane perforation 90% of cases
cholesteatoma
What are some medications for the management of vertigo?
diazepam (valium)
meclizine HCl (antivert)
diphenhydramine (benadryl)
scopolamine patch
antiemetics
sensorineural hearing loss, vertigo, & tinnitus
Meniere’s disease
Weber test normal
sound heard bilaterally, does not lateralize
Rinne test normal
AC > BC
Conductive loss Weber & Rinne
Weber- sound materializes to affected ear
Rinne- Abnormal in affected ear (AC < BC)
Sensorineural loss Weber & Rinne
Weber- sound materializes to the unaffected ear
Rinne- normal in affected ear
watery rhinorrhea
erythematous nasal mucosa
sneezing, nasal/sinus blockage, HA, sore throat, cough, malaise
common cold; viral rhinitis
anterior cervical adenopathy
macropapular rash
fever
strep throat
Centor criteria for strep (FLEA)
very specific test- the negatives test negative
if 2 or more yes- do rapid strep
Fever >100.4
Lack of cough
Phargynotonsillar Exudate
Anterior cervical adenopathy
management of strep throat
PCV V
erythromycin if PCN allergic
ABRUPT onset of fever, HA, myalgia, coryza, anorexia, malaise, cough
influenza
management of flu
neuraminidase inhibitors
- zanamivir (relenza) inhaler
- oseltamivir (tamiflu) oral
shorten duration of s/s by 2 days
white tonsillar exudates
posterior cervical adenopathy
fever, chills, SEVERE malaise/fatigue, anorexia, pharyngitis, splenomegaly
Mono (Epstein-Barr virus)
management of mono
supportive care
prednisone/steroid taper for severely enlarged tonsils
avoid contact sports for 3 weeks- months (to prevent splenic rupture)
inflammation of mucous membranes lining one or more of the paranasal sinuses
recent URI, with relapse
red nasal mucosa
pain/pressure over face, cheeks, teeth
postnasal drip
fever
HA- supine or bending
decreased transillumination
sinusitis
management of bacterial sinusitis
amox w/ clav (Augmentin)
clarithromycin (Biaxin)
Skin
circumscribed flat area of skin
different in color & texture from surrounding tissue
<1cm in size
ex. freckle, petechiae, flat nevi
macule
large macule, >1cm in size
ex. mongolian spot, cafe au lait
patch
small, solid, elevated lesion
<1cm in diameter
ex. ant bite, elevated nevus, verruca (wart)
papule
elevation of skin
1cm in diameter
ex. psoriasis
plaque
a visible accumulation of purulent fluid under skin
<1cm
ex. acne, impetigo
pustule
circumscribed elevation of skin containing serous fluid
<1cm
herpes, varicella
vesicle
solid mass of skin
observed as an elevation or can be palpated
1cm in diameter
often extends into the dermis
ex. xanthoma, fibroma
nodule
“blister”
circumscribed elevation containing fluid
1cm in diameter
extends only into the epidermis
ex. burns, superficial blister, contact dermatiti
bulla
elevated white or pink compressible papule or plaque
a red, axon-mediated flare often surrounds it
commonly associated with allergic reactions
ex. PPD test, mosquito bites
wheal
any closed cavity or sac
contains fluid or semisolid material
normal or abnormal epithelium
ex. sebaceous cyst
cyst
a localized collection of purulent fluid in a cavity formed by disintegration or necrosis of tissues
1cm in size
abscess
“mass”
a few cm in diameter
firm or soft
benign or malignant
tumor
LIVE vaccines
varicella
MMR
zoster
flu mist
most frequently used topical antibiotic for acne
clindamycin
PO antibiotics for acne
- tetracycline- don’t use in pregnancy and <9yo
- erythromycin, minocycline, doxycycline, clindamycin
2 major skin pathogens
Staph
Strep
boil that looks like a spider bite
MRSA
inflamed area of skin
cellulitis
most common pathogens of cellulitis
Group a strep
s. aureus
management of CA-MRSA
TMP-SMZ (bactrim)
doxy/mino
clindamycin
if area of very low CA-MRSA infection
dicloxacillin
or cephalexin (Keflex)
management of Group A strep
- TMP-SMZ plus beta lactam (PCN, amox, or 1st gen cephalosporin like keflex)
- doxy/mino plus beta lactam
- clinda
Which antibiotic will cover both CA-MRSA & Strep
clinda
looks like a big sunburn
bright, red, warm
rapid progression of erythema
usually cause by Strep
erysipelas
Staph infection
groin or axilla
hidradenitis suppurativa
What treatment for minor skin infections?
consider topical- bacitracin, bactroban (mupirocin)
1st gen cephalosporin- cephalexin (Keflex)
PCNase- resistant PCN (dicloxacillin)
alternatives: clinda or amox-clav
What pathogen is impetigo usually caused by?
staph aureus
What is paronychia?
staph around nail fold
bruise under finger nail
and its treatment
subungual hematoma
trephination- drill a hole
inflammation of the superficial tissues of the penile head caused by Candida albicans
and its treatment
candida balanitis
miconazole, clotrimazole, steroids, fluconazole
irritation of the fold of the skin, commonly occurring in warm, moist body areas
& its treatment
candida intertrigo
drying with talc or cornstarch
topical antifungals
po antifungals
treatment for capitus
selenium shampoo
What 2 meds for post-herpectic neuralgia
gabapentin (neurontin)
pregabalin (lyrica)
small patches in sun-exposed parts of body
premalignant
rough, flesh colored, pink or hyperpigmented
actinic keratosis
What can AKs progress to?
squamous cell carcinoma
management of AKs
liquid nitrogen
firm, irregular papule or nodule
develop over a few months
3-7% metastasize
prolonged, sun-exposed areas in fair skinned
keratitic, scaly bleeding
squamous cell carcinoma
common on geros
benign, not painful lesions
beige, brown or black plaques
stuck on appearance
seborrheic keratoses
treatment of seborrheic keratoses
none
liquid nitro
most common skin CA
slow growing
waxy, pearly appearance
central depression or rolled edge
telangiectatic vessels
basal cell carcinoma
mortality rate highest of all skin CAs
dx at 40yo
metastasize anywhere
malignant melanoma
What is the initial treatment for psoriasis?
tar/salicylic acid shampoo
topical steroids (BMTZ)
UVB light exposure
mild, acute inflammatory disorder
more common in females during spring and fall
pruritic rash on trunk and proximal extremities
initial lesion 2-10cm: “herald patch”
generalized rash within 1-2 weeks
lesions in Christmas tree pattern
eruption lasts 4-8 weeks
pityriasis rosea
What tests do you order if you suspect lyme?
ELISA initial
Western blot confirmatory
management of lyme
doxy
amox
What kind of rash do you have with lyme vs. rocky mountain spotted fever?
lyme- erythema migrans
RMSF- maculopapular rash, petechial rash
What tests for RMSF?
PCR
immunohistochemical IHC staining
Indirect immunofluorescence assay (IFA) for R. rickettsii antigen
sudden onset flu-like symptoms
1st lesions on oral mucosa/palate, face, or forearms
centrifugal distribution with greatest concentration of lesions on face and distal extremities
all lesions in same stage of development
scabs leading to deep, pitted scars
excruciating pain
small pox
no cure, only supportive
pruritic papule leading to ulcer surrounded by vesicles
arms/hands, followed by face and neck
black necrotic eschar with edema
cutaneous anthrax- report to heath department
antibiotic for anthrax
PCN
cipro
doxy
Endocrine
insulin dependent
juvenile onset
human leukocyte antigens (HLA-DR3 or HLA-DR4)
islet cell antibodies
ketones
poly’s- uria, dipsia, phagia
DM1
lab findings DM1
random glucose >200 with polyuria, polydipsia, weight loss
ketonemia, ketouria
BUN/creat elevated
What lab specific to DM 1?
human leukocyte antigens (HLA-DR3 or HLA-DR4)
normal BUN
normal creat
10-20
.5-1.5
which one fluctuates?
BUN- elevated with dehydration
most sensitive indicator of renal fxn?
serum creatinine
good a1c
6
What percent of diet should be carbs?
55-60%
when should insulin be started?
ketones
how should insulin be split up during the day? include dosage
0.5 u/kg/day with 2/3 of dose in am, 1/3 evening
review pg. 228-230
nocturnal hypoglycemia develops a stimulating surge of counter regulatory hormones.
hypoglycemic at 0300, rebounds with elevated blood glucose at 0700
Somogyi effect
treatment of Somogyi
reduce/omit bedtime dose of insulin
tissue becomes desensitized to insulin nocturnally; progressive elevation of glucose at night
elevated glucose at 0700
Dawn phenomenon
treatment of Dawn phenomenon
add/increase the bedtime dose of insulin
most common presentation of hyperthyroidism?
Grave’s
most common presentation of hypothyroidism?
Hashimoto’s
most important lab for hyperthyroid? Most important for hypothyroid?
Hyper- T3, Hypo- T4
hyperthyroidism
TSH ?
T3 ?
TSH down
T3 up
hypothyroid
TSH ?
T4 ?
TSH up
T4 down
symptomatic treatment of hyperthyroid
propranolol (inderal) 10-80mg qid
meds of hyperthyroid
thiourea drugs- methimazole (tapazole) 30-60mg qd in 3 doses
propylthiouracil 300-600mg qd in 4 doses
radioactive iodine 131-I to destroy goiters
lugol’s solution 2-3gtts po qd x10d to reduce vascularity of gland
ACTH hyper secretion by pituitary
adrenal tumors
chronic administration of glucocorticoids
Cushing’s syndrome
s/s of Cushings
central obesity
moon face, buffalo hump
acne
poor wound healing
purple striae
hirsutism
HTN from vasoconstriction
weakness
amenorrhea
impotence
HA
polyuria, thirst
labile mood
frequent infections
deficient cortisol, androgens, aldosterone
autoimmune destruction of adrenal gland
mets CA
bilateral adrenal hemorrhage from anticoagulant therapy
pituitary failure resulting in decreased ACTH
Addison’s disease (primary adrenocortical insufficiency)
s/s of Addison’s
hyperpigmentation in buccal mucosa and skin creases (knuckles, nail beds, nipples, palmar creases, and posterior neck)
diffuse tanning and freckles
orthostasis and hypotension
scant axillary and pubic hair
rapid worsening of chronic s/s (acute)
fever (acute)
LOC changes (acute)
outpatient management of Addison’s
glucocorticoid and mineralocorticoid replacement
hydrocortisone (glucocorticoid)
fludrocortisone acetate (Florinef) mineralocorticoid
labs of Cushings
hyperglycemia
hypernatremia
hypokalemia
labs of Addisons
hypoglycemia
hyponatremia
hyperkalemia
Musculoskeletal
What lab would be important before high-dose NSAIDs?
renal fxn
BUN & creat- esp creat
knee locking & immediate swelling
meniscal tear
palpable/audible click when knee is raised slowly with one foot externally rotated
test for medial meniscal injury
McMurray’s test
knee in 20-30 degree flexion, grasp leg wit one hand with anterior force to proximal tibia while opposite hand stabilizes the thigh (graded 1+ to 3+)
assess for anterior/posterior cruciate ligament tear
Lachman (drawer) test
patient prone
flex knee 90 degrees, pressure on heel with one hand while rotation the lower leg internally and externally
pain or click is positive for medial or lateral collateral ligament damage and/or meniscus injury
Apley’s grind test
up to how many steroid injections per year?
3
What are the dangers of too many steroid injections?
breaks down joint tissue
endocrine dysfunction- Addison’s crisis- no steroid made by body- hypotension
Heberden’s nodes and Bouchard’s nodes seen with which type of arthritis?
osteo
Heberden’s are where
distal interphalangeal nodes (DIPs)
Bouchard’s are where
proximal interphalangeal nodes (PIPs)
test for carpal tunnel that involves tapping over median nerve
Tinel’s sign
put them in the pharaoh position for 1 min (wrist flexion)
Phalen’s test
quad muscle weak
pain radiates into medial malleolus, numbness along the same path especially medial aspect of knee
*decr/absent patellar reflex
screening exam: have patient squat and rise
L3-L4 disk pathology
weakness with dorsiflexion of great toe and foot
pain radiated into lateral calf; numbness of dorsum of foot and lateral calf
screening exam: have patient walk on heels of foot
L4-L5 disk pathology
weakness of plantar flexion of great toe and foot
pain along buttocks, lateral leg and lateral malleolus; numbness to lateral aspect of foot and in posterior calf
diminished/absent Achilles reflex
screening exam: have patient walk on toes
L5-S1 disk pathology
benign neuroma causing a compression neuropathy of an inter metatarsal plantar nerve, most commonly of the 3rd or 4th inter metatarsal spaces
high heels with closed toes
“standing on a pebble”
shooting pain affecting the contiguous halves of 2 toes
tingling/numbness in the toes
morton’s neuroma
inflammation of plantar fascia, the thick tissue on the bottom of the foot that connects the heel bone to toes and creates the arch of the foot
foot arch pain/problems
common in runners
pain and stiffness in the bottom of the heel
pain worse in the am
plantar fasciitis
rupture of growth plate at the tibial tuberosity as a result of stress on the patellar tendon
painful limp with pain below knee cap
one or both legs
pain worse with activities
swelling
Osgood-Schlatter disease
management of Osgood-Schlatter disease
RICE
NSAIDs/tylenol
rare cases- surgery referral
an inflammatory disorder involving pain and stiffness in shoulder and usually the hip
over 50yo
may be associated with temporal arteritis
stiffness in neck, shoulders, and hips
loss of ROM in area
fatigue, anemia, mild fever
polymyalgia rheumatica
What lab will be increased with polymyalgia rheumatica?
ESR
management of polymyalgia rheumatica
corticosteroids
symptomatic treatment
STDs
What is the initial test for HIV?
ELISA
What is the confirmatory test for HIV?
Western Blot
What is the normal CD4 lymphocyte count?
800
What is the CD4 count that is considered AIDS?
<200
What is the ideal viral load?
<5000
You want the _ to be high and the _ to be low?
CD4
viral count
What is the leading killer of AIDs patients?
Pneumocystis jirovecii (PCP pneumonia)
they take bactrim qd for this
When does the CDC recommend AART be started?
CD4 350
gram-negative bacillus
co-factor for HIV
painful, erythamatous base with halo
ulcers may be necrotic or severely erosive
chancroid
the degree to which those who have a disease screen/test positive
sensitivity
the degree to which those who do not have a disease screen/test negative
specificity
if there is a question about sensitivity, you would mark hose who DO/DO NOT have it
DO, remember +
if there is a question about specificity, you would mark those who DO/DO NOT have it
DO NOT, remember –
Treatment of chancroid
1 gm azithromycin
or
250 mg IM ceftriaxone (rocephin)
or
Cipro 500 mg PO bid x3 days
The 2 STDs where it hurts when they pee
Gonorrhea and chlamydia
What 4 things cause dyspareunia in women?
chlamydia
PID
menopause
trich
treatment for chlamydia
1gm azithromycin x1 dose
or
doxycycline 100mg bid x7 days
or
alternatives erythromycin, ofloxacin, levofloxacin
treatment for gonorrhea
Ceftriaxone (rocephin) 250mg IM x1
plus give 1gm azithro PO x1 to cover chlamydia
fever, malaise, dysuria, painful/pruritic ulcers on genitalia
lasting for usually 12 days
initial herpes outbreak
recurrence with less painful ulcers lasting for __ days
5
which vir drug especially useful for asymptomatic viral shedding of HSV 2
valacyclovir
immunotypes L1, L2, or L3 of Chlamydia trachomatis
2-3 mm painless vesicle, bubo, or non-indurated ulcer
regional adenopathy
lymphogranuloma venereum (LGV)
treatment of lymphogranuloma venereum (LGV)
Doxy 100 mg bid x21 days
aspirate buboes to prevent ulcerations
lesions are 1-5mm smooth, rounded, firm, shiny flesh-colored to pearly-white papules
common on trunk and anogenial region
molluscum contagiosum
treatment of molluscum
cryo with liquid nitro
treatment of syphilis
benzathine PCN G 2.4 million units IM
PCN allegic- doxy 100 mg bid or erythro 500 mg qid
GYN
malodorous, frothy yellow-green discharge, pruritus, vaginal erythema, “strawberry patches” on cervix and vagina, dyspareunia, dysuria
trichomonas
how to do wet-prep for trich?
Normal saline shows motile trichomonads
watery, gray, fishy smelling discharge, vaginal spotting
BV
thick, white, curd=like discharge, vulvovaginal erythema with pruritus
candidiasis
Wet prep for BV?
normal saline shows clue cells
Wet prep for candidiasis?
KOH mixture shows pseudo hyphae
treatment of trich
metronidazole (Flagyl) 2gm PO x1 or 500mg bid x7days
treatment of BV
metronidazole (Flagyl) 500mg bid x7 days or 2gm PO x1
gel 0.75% 5gm intravag bid x5 days
or
clindamycin (Cleocin) vag cream 2% 5gm qhs x 7days or 300mg bid x7days
treatment of candidiasis
miconazole or clotrimazole 1 % 5gm vag qhs x7days
terconazole 80mg suppository qhs x3days
the flu + gyn
+CMT
adnexal tenderness
abd tenderness
fever
dyspareunia
PID
treatment of PID
page 260
What are the 3 major concerns when considering hormonal therapy for menopausal symptoms?
- breast cancer
- uterine cancer
- MI/CAD risk- consider lipid panel, metabolic syndrome
if not clear, refer
DEXA
what is the normal T score?
-1.0 SD
osteopenia T score
-1.0 to -2.5
osteoporosis T score
below -2.5
dietary sources of calcium
dairy, sardines, salmon w/ bones, green leafy vegetables, tofu, calcium fortified foods, take vit D
management of lower UTI
x3 days
TMP-SMZ (Bactrim)
Cipro
Amox w/ clav (Augmentin)
other considerations
amoxicillin, levofloxacin, nitrofurantoin (Macrobid, Macrodantin),
UTI during pregnancy
x7-10 days
amoxicillin
nitrofurantoin (Macrobid) until 36 weeks
cephalexin (Keflex)- never really used
What is the black box warning about cipro?
achilles tendon rupture
usually younger man
UTI symptoms
marked scrotal edema
usually chlamydia in <35yo
epididymitis
Positive Prehn’s sign
lift scrotum to symphysis pubis- pain relieved
treatment for epididymitis <35
Ceftriaxone (rocephin) 250 IM x1 and doxy (vibramycin) 100mg bid
or
azithro 1gm PO x1
treatment for epididymitis >35
TMP-SMZ (Bactrim) DS bid x10d
or
Cipro 250mg bid x10d
UTI-like in man
usually E.Coli gram –
fever, chills, low back pain, dysuria, urgency/frequency, nocturne
edematous prostate, may be warm, tender/boggy to palpation, pain
acute bacterial prostatitis
antibiotic choices for acute bacterial prostatitis
TMP-SMZ (bactrim)
or fluoroquinolones- levoflox, norflox, oflox
s/s
urgency/frequency, nocturia, dribbling, retention
bladder distention
non-tender prostate symmetrical/asymetrical enlargement
smooth, rubbery consistency
BPH
2 med classes and 1 herb for BPH
alpha-blockers (relax muscles of bladder and prostate)- terazosin (hytrin), prazosin (minipress), tamsulosin (flomax)
5-alpha-reductatse inhibitors (shrink large prostates)- finasteride (proscar) and dutasteride (avodart)
Saw palmetto- effective for some
Psychosocial
difficulty with speech
aphasia
inability to perform a previously learned task
apraxia
inability to recognize an object
agnosia
What are the meds for Alzheimer’s disease?
acetylcholinesterase inhibitors
donezepil (aricept)
galantamine (razadyne)
rivastigmine (exelon)
vise-like or tight quality
usually generalized
intense about neck or back of head
no neuro symptoms
several hours
tension headache
which cranial nerve associated with migraine?
trigeminal- V
What would you use sumatriptan (imitrex) for?
migraine and cluster
a degenerative disorder as a result of insufficient amounts of dopamine?
parkinson’s disease
trio of finds for parkinson’s
tremor, rigidity, bradykinesia
GI
Anti-HAV, IgM
active Hep A
Anti-HAV, IgG
recovered Hep A
ABsAG, HBeAg, Anti-HBc, IgM
active Hep B
ABsAG, Anti-HBc, IgM, IgG
chronic Hep B
Anti-HBc, Anti-HBsAg
recovered Hep B
Anti-HCV, HCV RNA
same in chronic and acute Hep C
Cardiac
What happens during S1?
mitral/tricuspid (A/V) valves close
What happens during S2?
aortic/pulmonic (semilunar) valves close
What is systole?
period between S1 and S2
What is diastole?
period between S2 and S1
What does S3 mean?
Ken-tuck-y, increased fluid states (CHF, pregnancy)
What does S4 mean?
Ten-ne-ssee, stiff ventricular wall (MI, left ventricular hypertrophy, chronic hypertension)
Hematologic & oncologic disorders
Hct normal male/female
40-54% M, 37-47% F
TIBC- capacity to store iron
250-450
Serum iron
50-150
MCV- microcytic/macrocytic SIZE normal
80-100
MCH- expression of av amount & weight of Hgb in a single RBC normal
26-34
MCHC- hypochromic/normochromic normal
32-36
2 anemias with low MCV- small in size
IDA, thalassemia
2 anemias with high MCV- big- megaloblastic
B12 or folate deficiency; also, alcohol, liver fx, drugs
Normocytic anemia
anemia chronic disease, sickle cell, renal fx, blood loss, hemolysis
Iron deficiency labs
Microcytic, hypochromic
Low Hgb, Hct, MCV, MCHC, RBCs, iron, ferritin
High TIBC
High RDW
Management of IDA
ferrous sulfate 300-325mg qd-bid
Foods high in iron
raisins, green leafy veggies, red meats, citrus, iron fortified breads/cereals
Thalassemia labs
Microcytic, hypochromic
Low Hbg, MCV, MCHC,
Normal TIBC, normal ferritin
Thalassemia management
Usually nothing
RBC transfusion/splenectomy if severe
iron contraindicated
Folic acid def labs
Macrocytic, normochromic
Hct & RBCs decreased
MCV increased
MCHC normal
Serum folate low
RBC folate <100
Folic acid def signs
fatigue etc.
Glossitis
NO neuro symptoms vs B12 does
Treatment folic acid def
1mg folate qd
foods: bananas, peanut butter, fish, green leafy, iron fortified breads/cereals
Pernicious anemia labs
Hgb, Hct, RBCs decreased
MCV increased
Serum B12 <0.1
Anti IF (intrinsic factor) and anti parietal cell antibody test
Schilling test for cause
Pernicious anemia signs
glossitis, NEURO signs- paresthesia, loss vibratory sense, fine motor control, + ROMBERG, + BABINSKI
Pernicious anemia treatment
B12 100 IM qd x1week
then q month for life
anemia of chronic disease labs
normocytic, normochromic
Hgb, Hct low
MCV normal
MCHC normal
Serum iron & TIBC low (capacity for more iron is low)
Ferritin high (stores of iron high)
Anemia chronic disease treatment
Treat underlying disease
Nutritional support
Sickle cell labs
Hgb low
peripheral smear shows sickled cells
cellulose acetate and citrate agar gel electrophoresis to confirm Hgb genotype
Sickle cell crisis treatment
fluids, pain management
leukemia definition
neoplasms arising from hematopoietic cells in bone marrow
80% of acute leukemia in adults
remission 50-85%
long-term survival ~40%
Acute nonlymphocytic leukemia (ANL)/ Acute myelogenous leukemia (AML)
more difficult to cure in adults than children (90% remission in children)
pancytopenia with circulating blasts is hallmark of disease (all lab values decreased)
Acute lymphocytic leukemia (ALL)
most common leukemia in adults
occurs in middle age and old age
median survival 10 years
lymphocytosis (large increase 42K) is hallmark of disease
Chronic lymphocytic leukemia (CLL)
occurs in individuals 40 and older
median survival 3-4 years
Philadelphia chromosome seen in leukemic cells is hallmark of disease
Chronic myelogenous leukemia (CML)
S/S leukemia
asymptomatic
fatigue, weakness, anorexia
generalized lymphadenopathy
weight loss
Labs leukemia
Subnormal RBCs and neutrophils
Elevated ESR
Bone marrow req for confirmation
Management of leukemia
chemo
bone marrow transplant
Non-Hodgkin’s lymphoma
unknown etiology, may be viral
lymphadenopathy
common 20-40
diffuse small b cells found
Hodgkin’s desease
males, 32 years old
cause unknown
cervical adenopathy, spreads predictably along lymph groups
Reed-Sternberg cells
Lymphoma management
radiation
chemo
sometimes bone marrow transplant
Psychosocial disorders
Depression- In Sad Cages
Interest- loss of pleasure
Sleep disturbances
Appetite changes
Depressed mood
Concentration difficulty
Activity- agitation/retardation
Guilt feelings or low self-esteem
Energy loss
Suicidal ideation
Alcoholism- Cages questionnaire
C- have you ever felt the need to cut down on your drinking?
A- have people annoyed you by criticizing your drinking?
G- have you ever felt guilty about your drinking?
E- have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (eye-opener)
cause of Alzheimer’s
acetylcholine deficiency
meds of Alzheimer’s
acetylcholinesterase inhibitors
donezepil (Aricept)
galantamine (Razadyne)
rivastigmine (Exelon)
often prescribed in conjunction with NMDA receptor antagonists such as memantine (Namenda) to improve thinking and activities of daily living
Cognitive defect definitions
test for object recognition
recognize a paperclip in the palm
steriognosis
draw 6 in palm
gravisthesia
aphasia
difficulty with speech
apraxia
inability to perform a previously learned task
agnosia
inability to recognize an object
Cranial nerves mnemonic
On Some
Old Say
Olympus Marry
Towering Money
Tops But
A My
Fin Brother
And Says
German Big
Viewed Bras
Some Matter
Hops Most
CN 7- facial. Which disease?
Bell’s palsy
Entirely sensory
1, 2, & 8
Move the eyes
3, 4, & 6
CN associated with migraine
5-trigeminal
Meds for daily prophylactic therapy of migraines occurring more than 2-3x per month
amitriptyline (Elavil)
dialproex (Depakote)
propranolol (inderal)
imipramine (tofranil)
clonidine (catapres)
verapamil (Calan)
topiramate (Topamax)
gabapentin (neurontin)
methysergide (sansert)
magnesium
Meds for acute migraine
ASA
Sumatriptan (Imitrex) 5mg SQ at onset, repeat in 1h, total of 3x per day
What 2 types of HA do you use sumatriptan (Imitrex) for?
migraine
cluster
sign of stroke w/ altered vision- ipsilateral monocular blindness
amaurosis fugax
1 cause of heart failure
HTN
Simple partial seizure
common w/ cerebral lesions
NO loss of consciousness
rarely >1min
motor symptoms in one muscle group, spread to entire side of body
paresthesias, flashing lights, vocalizations, hallucinations
Complex partial seizure
simple partial followed by impaired level of consciousness
may have aura, staring, or automatisms such as lip smacking and picking at clothing
absence (petite mal)
arrest of motor activity w/ blank stare
tonic-clonic (grand mal)
may have aura
Contractions (tonic), loss of consciousnes, then clonic (maintained involuntary contraction of muscle)
last 2-5 min
incontinence may happen
postictal period
status epilepticus
medical emergency
series of grand mal >10min
don’t gain consciousness between attacks
most uncommon, but life-threatening
Labs/diagnostics
EEG- seizure classification
CT- for new onset seizures
Management of seizures
supportive
protect from injuries, nothing in airway
Benzos- Diazepam (valium) or lorazepam (ativan)
Phenytoin (dilantin)
Fosphenytoin (cerebyx) prodrug of dilantin
Phenobarb (luminal) if phenytoin unresponsive
Seizure prevention meds
Carbamazepine (tegretol)
phenytoin (dilantin)
phenobarb (luminal)
valproic acid (depakene)
primidone (mysoline)
clonazepam (klonopin)
Parkinson’s definition
degenerative disorder as a result of insufficient amounts of dopamine in the body
trio of findings in Parkinson’s
tremor
rigidity
bradykinesia
2 med classes in Parkinson’s
- increase dopamine- Carbidopa-levodopa, amantadine, tolcapone, pramipexole
- anticholinergics tremors/rigid- benztropine, trihexyphenidyl
Myasthenia gravis
autoimmune, reduction of number of acetylcholine receptor sites at the neuromuscular junction
weakness worse after exercise, better after rest
Myasthenia gravis s/s
***ptosis
diplopia, dysarthria, dysphagia, extremity weakness
sensory modalities and DTRs normal
Myasthenia gravis labs
antibodies to acetylcholine receptors
edrophonium (Tensilon) test to differentiate a myasthenic vs. cholinergic crisis
Myasthenia management
anti cholinesterase drugs- pyridostigmine
immunosuppressives
plasmaphoresis
ventilator support
MS def
autoimmune, attacks myelin
MS s/s
weakness, numbness, tingling, unsteadiness of limb
spastic paraparesis
diplopia
MS findings
Mild lymphocytosis common
elevated protein in CSF, CSF IgG
MRI
MS management
steroids for acute
antispasmodics
***interferon therapy
immunosuppressive therapy
plasmapheresis
Bell’s CN
CN 7, usually right side of face
Bell’s treatment
Prednisone taper 7-10 days
Acyclovir
eye drops and patch if can’t close eyes
Trigeminal neuralgia
stabbing, electric shock in part of face
Trigeminal neuraligia management
anti-seizure drugs
muscle relaxants
TCAs
GI
murphy’s sign
cholecystis
diverticulitis
female, older, LLQ px
gnawing epigastric pain
epigastric tenderness
H. pylori
NSAIDs, ASA, glucocorticoids
smokers
stress
PUD
What kind of ulcers in older 55-65y?
gastric
What kind of ulcers in younger 30-55y?
duodenal
relief of pain with eating
duodenal ulcer
more pain eating
gastric ulcer
1st line PUD
H2 receptor antagonist
$4 drug list
cimetidine (tagamet) 800mg qhs
ranitidine (zantac) 300mg qhs
famotidine (pepcid) 40mg qhs
nizatidine (axid) 300mg qhs
2nd consideration for PUD- diagnosed officially
PPIs
30 min before meals
lansoprazole (prevacid)
rabeprazole (aciphex)
pantoprazole (Protonix)
omeprazole (prilosec)
dexlansoprazole (dexilant)
esomeprazole (nexium)
basic combo therapy for H. pylori eradication
2 antibiotics + PPI or bismuth
pain with right thigh extension
Psoa’s sign
pain with internal rotation of flexed right thigh
obturator sign
RLQ pain when pressure applied to LLQ
positive Rovsing’s sign
Lower respiratory
normal percussion sound of chest
resonance
asthma percussion
hyperresonance
mainstay of COPD treatment (chronic bronchitis and emphysema)
inhaled anticholinergic- ipratropium bromide (Atrovent)
most common bug in CAP
Strep pneumoniae
treatment of CAP
healthy, young- macrolide (azithromycin), clarithromycin (Biaxin), erythromycin, or doxycycline
unhealthy, old- fluoroquinolone- levofloxacin (Levaquin), gemifloxacin (Factive), or moxifloxacin (Avelox)
Cardiovascular
ST segment changes with angina vs MI
Angina- down sloping/depression of ST
MI- ST elevation
Total cholesterol normal
<200
Trigylcerides
<150
HDL
40
LDL
Gen pop <130
2+ risks <100
diabetic, previous MI <70
3 common med categories for the outpatient treatment of angina
Nitrates
Beta blockers
CCBs
Meds for hyperlipidemia
Statin
Niacin if not controlled
If still trouble, time for fibrate (gimfibrazol)
Extra heart sound common with infarct
S4
ECG changes with MI
Peaked t waves, ST elevation, Q waves
Leads I, aVL
lateral MI
II, III, aVF
inferior MI- bottom of heart dying
V leads or V3 and V4
anterior MI
Cardiac enzymes
CK-MB, Troponin I are 100% cardioselective
then Troponin T
Hx CAD, 68yoM, hyperlipidemia, smokes 2ppd, diabetic, calf hurts, numbness to toes, pain
Exam: shiny, hairless skin, w/ dependent rubor, and elevational pallor, ulcerations
Doppler, ABI, arteriography
-stop smoking, exercise
-Pentoxifylline, cilostazol
PVD-atherosclerotic narrowing
Woman, maybe genetic, aching of LE’s, relieved by elevation, edema when up on feet, night cramps, trophic changes, brown blotches, dermatitis
use stockings, bed rest w/ elevated legs
CVI- impaired venous return
low pitched rumble during 1st heart sound
mitral stenosis
EENT
What does it mean if the cup is more that 1/2 the size of the disc diameter?
glaucoma
retinal vessels
arteries vs veins
arteries brighter and narrower
A:V ratio 2:3 or 4:5
raised area where A & V meet
nicking = htn
hyperopia
farsighted = old people
myopia
nearsighted = young people
presbyopia
common after 40, difficult maintain clear focus at a near distance due to decr. flexibility of lens and weakening of the ciliary muscles
arcus senilis
cloudy appearance of the cornea with a gray/white arc or circle around the limbus due to deposition of lipid material = hyperlipidemia
hordeolum (stye)
infection, S. aureus
pain and erythema
warm compress
topical bacitracin or erythromycin
chalazion
beady nodule on eye lid
infection or retention cyst of a meibomian gland
painless aside from swelling
warm compress & surgery referral
blepharitis
Staph infection or seborrheic dermatitis of the the lid edge
eyes itching, burning, redness, tearing, blurred vision, swelling of eyelids, foreign body sensation
NO PAIN
conjunctivitis
Increased intraocular pressure
glaucoma
asymptomatic
elevated IOP
cupping of the disc
constriction of visual fields- decr visual fields
open-angle
acute
extreme pain, blurred vision, halos around lights, pupil dilated/fixed
closed-angle
clouding and opacification of the normally clear lens of the eye
cataracts