1. Define diagnostic reasoning
2. What is subjective data?
3. What is objective data?
4. Identify components of HPI
5. Describe thhe differences between medical billing & medical coding.
6. Compare & contr
...
1. Define diagnostic reasoning
2. What is subjective data?
3. What is objective data?
4. Identify components of HPI
5. Describe thhe differences between medical billing & medical coding.
6. Compare & contrast thhe two coding classification systems that are currently used in thhe US healthcare system.
7. How do specificity, sensitivity, & predictive value contribute to thhe usefulness of diagnostic data?
8. Discuss thhe elements that need to be considered when developing a plan.
9. Describe thhe components of medical decision making in E&M coding.
10. Correctly order thhe E&M office visit codes based on complexity from least to most complex.
11. Thhe 5 key components of a comprehensive treatment plan are:
12. Define thhe components of a SOAP note.
13. Discuss minimum of three purposes of thhe written history & physical in relation to thhe importance of documentation.
14. Why does every procedure code need a corresponding diagnosis code?
15. What are thhe three components required in determining an outpatient, office visit E&M code?
16. Correctly ID a pt as a new or established given historical info.
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17. What does a well-rounded clinical experience mean?
18. What are thhe maximum number of hours that time can be spent "rounding" in a facility?
19. What are 9 things that must be documented when inputting data into clinical encounter logs?
20. What does thhe acronym SNAPPS st& for?
21. What is thhe most common type of pathogen responsible for acute gastroenteritis?
22. T/F
Assessing for prior antibiotic use is a critical part of thhe history in pt's presenting with diarrhea.
23. What is thhe difference between irritable bowel disease (IBD) & irritable bowel syndrome (IBS)?
24. What are two common IBD's?
25. Describe thhe characteristics of acute diverticulitis.
26. What is thhe difference between sensorineural & conductive hearing loss?
27. What is thhe triad of symptoms associated with Meniere's disease?
28. What symptoms are associated with peritonsilar abscess?
29. What is thhe most common cause of viral pharyngitis?
30. What is thhe most common cause of acute n/v?
31. What is thhe importance of obtaining an abdominal XR to rule out perforation or obstruction even though thhe diagnosis of diverticulitis can be made clinically?
32. What are colon cancer screening recommendations relative to certain populations?
33. Identify at least two disorders that are considered to be disorders related to conductive hearing loss.
34. What is thhe most common cause of bacterial pharyngitis?
35. What are thhe clinical findings associated with mononucleosis?
36. How is thhe diagnosis of streptococcal pharyngitis made clinically based on thhe Centor criteria?
37. What is one intervention for a pt with gastroenteritis?
38. When are stool studies warranted?
39. What is an appropriate treatment for prophylaxis or treatment of traveler's diarrhea?
40. Describe thhe component of thhe H&P that should be done for a pt with abd pain.
41. What is at least one effective treatment for IBS?
42. What is at least one prescription med used to treat chronic constipation?
43. What is at least one treatment for Meniere's disease?
44. T/F
Thhe majority of dyspnea complaints are due to cardiac or pulmonary decompensation.
45. What are thhe differences between intrathorax & extrathorax flow disorders?
46. What are at least 3 examples of flow & volume disorders (intra &/or extra thorax)?
47. Differentiate between rubeola, rubella, varicella, roseola, 5ths disease, pityriasis rosea, h&/foot/mouth, & molluscum contagiosum.
48. What are common characteristics in a rash caused by Group A strep?
49. What are treatment options for Group A B-hemolytic strep pharyngitis?
50. Differentiate between tinea pedis, cruris, corporis, & unguium. What are thhe appropriate treatments for each?
51. What is thhe virus that causes warts?
52. Differentiate between atopic & contact dermatitis. Give examples of each.
53. What is a normal response to TB skin tests & what does it mean?
54. What are some common reasons for decreased responsiveness to TB skin testing?
55. What are some common meds used to treat TB?
56. What is thhe MOA & common SE's of Isoniazid?
57. What is thhe MOA & common SE's of Pyrazinamide?
58. What is thhe MOA & common SE's of Ethambutol?
59. What are thhe different strengths of tretinoin & when is each appropriate?
60. Identify various types of lesions based on thheir characteristics:
Rubeola:
Pt looks ill
High fever
Red mucus membranes
Conjunctivitis
Nasal congestion
Reddish/purple generalized macular/papular rash
Lesions start on head (face/behind ears), spread over rest of body in 1-2 days
Rubella:
Low-grade fever
HA
Sore throat
Rhinorrhea
Malaise
Eye pain
Myalgia 2-5 days before rash
Rose-pink macules/papules
Lesions start on head, travel down body
Rash disappears in 1-2 days in same order it appeared
Varicella:
Malaise
Fever
Chills
HA
Arthralgia
1-2 days later, urticarial erythhematous macules/papules appear, quickly turning to vesicles/pustules
Rash starts on face/chest, spreads quickly over entire body, dry up in 1 week
Roseola:
High fever
Irritability
Diarrhea
Cough
Cervical lymphadenopathy
Light pink erythhematous macules/papules on face, neck, extremities, resolves in 1-3 days
Fifth's Disease:
Starts with HA, fever, chills, maybe cough
Stage 1: "Slapped cheek" rash
Stage 2: Pink lacy erythhematous macules on extremities/trunk, spares palms & soles. May be itchy.
Stage 3: 2-3 weeks of body rash
Pytiriasis rosea:
2-4 patches or plaques on trunk that starts 2-3wks before general rash, aka "herald patch"
Rash pink to erythhematous, round to oval plaques & papules with possibly scaly borders
Rash resembles shape of Christmas tree
Rash can be itchy
Low-grade fever
HA
Fatigue
Can last 1-2mo or longer
H&, foot, & mouth:
Mouth sores usually first to appear
H& vesicles are erythhematous halos, mostly soles & palms
Sometimes are on legs, butt, face
Usually resolve in 7 days
Molluscum contagiosum:
Tiny pustules 2-5mm
Flesh-colored dome, some have slightly depressed center
Single or multiple lesions
Kids: thighs & arms
Adults: genital region from sexual contact
Soles & palms always spared
Sometimes erythhematous & scaly
Can last 8mo or longer
Folliculitis:
Little pustules or erythhema around base of hair follicle
Abscesses:
Sac or pore filled with pus
Erythhematous, tender nodule that can be fluctuant
Furuncle:
infection that involves hair follicle & extends into surrounding tissue
Mostly on axillae, neck, buttock
Carbuncle:
Cluster of abscesses that connect subcutaneously to form mass
Group A strep:
Red s&paper rash
Fever
Bright red sore throat
Lymphadenopathy
Bright red skin in skin folds
Tinea pedis:
Erythhematous, scaly, possibly inflammation or itching on feet
Tinea Cruris:
Jock itch
Rash present on inner thighs, butt, groin
Well-demarcated erythhematous or tan plaques with raised scaly borders
Tinea corporis:
Ringworm
On extremities or trunk
Erythhematous annular lesion w/scaly macules/papules, well-defined edge
May be itchy
Edge is raised & center is inflamed
Tinea unguium:
Onychomycosis
Fingernails or toenails
Appearance varies: yellow, green, black, white ridging, cracking of nails
Warts:
HPV causes
Skin colored rough papule, sometimes grayish surface
Single lesions or clusters
Sometimes tiny black or red dots in lesions
Scabies:
Intense itching worse at night
Light pink curved or linear burrows, occasionally w/black dot on one end
Commonly in between fingers & toes
Aktinic keratosis:
Result of cumulative sun exposure & aging
Rough textured skin, maybe flesh or pink colored
Sometimes thick & scaly, can evolve into plaque
Sometimes stinging sensation when rub area
Lesion never goes away, no matter how much moisturizer used
Vitiligo:
Michael Jackson disease
Depigmented areas of skin
Well-demarcated
Macules or papules surrounded by normal skin
Contact dermatitis:
Allergic reaction to substance
Pruritic & erythhemic rash
Occurs on area that was directly exposed to reaction
Atopic dermatitis:
Patches of itchy, dry skin
Can be red to brownish-gray
May have small raised vesicles that leak when scratched
61. What are common characteristics associated with blepharitis, chalzion, & hordeolum.
Blepharitis: irritation, burning, itching, scales, redness.
If lice is cause: reddish brown crust in lashes (not white or clear as typically seen).
Chalzion: mass in mid-portion of upper lid away from margin. Usually not painful or tender. Slightly red, swollen.
Hordeolum: usually on outside of lid, abscess on lid margin. Redness, swelling, painful.
62. Differentiate between viral, allergic, bacterial, toxic, & HSV conjunctivitis.
Bacterial: aka pink eye.
Direct h&-to-eye contact w/infected person.
Spread of one's own nasal/sinus bacteria during illness.
Purulent discharge (HALLMARK)
Reddened conjunctiva
Eyelid swelling
Can start unilat, but can spread bilat.
May resolve without treatment, but abx drops can shorten duration.
Very contagious (stay home until 24hrs of abx treatment or when clinical improvement noted).
Viral: usually caused from adenovirus, but can be HSV, HZV, molluscum contagiosum.
Irritation, mild light sensitivity, swollen lids, mild FB sensation.
Mild conjunctival hyperemia to insense hyperemia. Watery/mucousy drainage, not purulent.
Enlarged tender preauricular lymph nodes on affected side.
Red throat, nasal drainage, ear infection, etc.
Self-limiting, resolve on thheir own from few days to few weeks.
Highly contagious
Current recommendation is stay home until redness/tearing resolved.
Allergic: usually caused by environmental allergen (pollen, grass, trees, etc.).
Can be seasonal & can be isolated to eyes or include upper resp allergy symptoms such as rhinitis.
Hallmark characteristic: itching
Diffuse, milky, conjunctival hyperemia
Swollen conjunctiva
Tearing
Almost always bilat
Uniquely identifying bumps on conjunctiva ("follicles")
Tx: symptomatic. Artificial tears, anti-allergy drops.
Toxic: due to overuse of topical ocular meds (Visine), but abx drops most common (usually from using abx drops for longer than prescribed or for viral infections).
Clear, watery discharge & red conjunctiva
Dx usually from history
Tx: stop thhe drops
HSV: spread by contact w/persons who have visible, infected lesions & w/persons symptomatically shedding thhe virus.
Pt may be experiencing prodrome of ill-related symptoms (malaise, low grade fever, pain/tingling near site of lesions but lesions not yet visible).
Skin vesicles
Conjunctivitis (same as viral)
Corneal infection w/hallmark dendrite appearance
63. Which chemical injury is associated with thhe most damage & highest risk to vision loss?
Moderate to severe alkali (ammonia, drain cleaners, cement, plaster/mortar, airbag rupture, fireworks; all contain ammonia, lye, lime, sodium, mag hydroxide).
64. Which cardiac or pulmonary disorders contribute to thhe majority of dyspnea complaints due to decompensation?
asthma;
chronic obstructive lung disease;
malignancy;
heart failure;
interstitial lung disease;
pneumonia;
valvular heart disease;
intracardiac shunt;
arrhythmias;
cardiomyopathies;
myocardial ischemia.
65. What are appropriate tests in thhe work-up for dyspnea?
CXR to rule out tumors, TB, PNA, othher major pulmonary disorders.
CBC w/diff to rule out anemia, infection
Peak expiratory flow test (in office) to determine degree of expiratory airflow obstruction in pt's with asthma, COPD
EKG
Echo
Spirometry to determine obstructive, restrictive, mixed lung dz
Sleep apnea or sleep hypoxia testing
66. Describe classes of asthma.
Mild intermittent:
Less than once weekly
Brief exacerbations lasting few hrs to few days
Nighttime symptoms <2/wk
PEFR or FEV1: >80% predicted
PFT variability >20%
Mild persistent:
Symptoms >2/wk but 80%
PFT variability 20-30%
Moderate persistent:
Daily but not continual
Nighttime, but not every night
More than once weekly
Exacerbations affect activity/sleep
Daily use of short-acting beta-2 agonist
PEFR or FEV1 60-80%
PFT variability >30%
Severe persistent:
Continuous daily
Frequent nighttime
Frequent exacerbations
Physical activity limited
PEFR or FEV1 < or = 60%
PFT variability >30%
67. What are thhe different treatments for thhe asthma classes?
Mild intermittent:
No daily meds
PRN inhaled short acting beta-2 agonist or cromolyn before exercise or allergen exposure
Mild persistent:
One daily controller med (inhaled corticosteroid), cromolyn/nedocromil, leukotriene modifiers
Inhaled beta-2 agonist PRN
Moderate persistent:
Daily meds: combo inhaled medium dose corticosteroid & long-acting bronchodilator: cromolyn-nedocromil, leukotriene modifiers
Severe persistent:
Inhaled beta-2 agonist PRN
Multiple daily controller meds: high dose inhaled corticosteroid, long-acting bronchodilator, cromolyn/nedocromil, leukotriene modifiers.
68. Identify respiratory characteristics of chronic bronchitis.
Characterized by excessive mucus secretion in bronchial tree
Manifests by chronic or recurrent cough (with or without sputum), present on most days for minimum of 3mo of thhe year for at least 2 consecutive years.
Pts usually use accessory muscles with respiration & have dyspnea with or whitout sheezing.
Pts may have s/s of right HF (edema, cyanosis).
FVC: normal to increased
RV: increased
TLC: normal
EFR: normal to decreased
FEV1/FVC: decreased
69. Identify respiratory characteristics of asthma.
Chronic, inflammatory, obstructive disease in airways.
May occur at any age & presents with wheezing (airway spasms), chest tightness, dyspnea, cough.
Reversible hyperreactivity of bronchi & bronchioles to a variety of stimuli.
FVC: normal
RV: normal, increased during attacks
TLC: normal to increased
EFR: normal to decreased
FEV1/FVC: normal to decreased
70. Identify respiratory characteristics of COPD.
Progressive disease characterized by presence of airflow obstruction due to chronic bronchitis or emphysema.
3rd leading COD in US.
Dz of lung parenchyma & small airways
Pts may be asymptomatic for 10-20yrs except for frequent colds, persistent morning cough, URIs.
Pts present with fatigue, SOB, cough, hyperinflation (barrel chest), wheezing, decreased breath sounds, hyperresonance.
Stage 1 (mild): FEV >80%.
Stage 2 (moderate): FEV 50-79%
Stage 3 (severe): FEV 30-49%
Stage 4 (very severe): FEV <30%
71. What is thhe CURB-65 tool & how is it used?
Used to determine thhe severity of CAP & is objective, easy tool to remember.
C: confusion
U: BUN >19
R: resp rate >30
B: BP syst <90 or diast <60
65: >65yo
1 point awarded for each.
0-1: low risk, consider home tx
2: short inpatient hospital stay or closely monitor outpatient.
3 or more: severe pna, hospitalize & consider ICU
72. What are subjective & objective findings with asthma?
Subjective:
SOB
CP/tightness
Objective:
Wheezing
Dyspnea
Excessory muscle use
Peak flow meter readings varied
Non-productive cough
73. What are subjective & objective findings with COPD?
Subjective:
SOB
Chest tightness
Urge to clear lungs in morning
Fatigue
Objective:
Wheezing
Cough w/sputum chronically & consecutively
Cyanosis
URIs diagnosed
Wt loss
Edema
74. What are subjective & objective findings with sinusitis?
Subjective:
HA
Pain in sinuses
Facial tenderness
Sore throat
Cough
Persistent symptoms lasting >7days
Objective:
Fever,
Discolored nasal drainage
Facial swelling
Bad breath
75. What are subjective & objective findings with allergic rhinitis?
Subjective:
itchy throat/nose/eyes
Watery eyes
Head/nasal congestion
Fatigue
Ear pressure
Sneezing
Objective:
Cobblestoning in back of throat
Post-nasal clear drip
Red eyes
76. What are subjective & objective findings with vasomotor rhinitis?
Subjective:
Stuffy nose
Congestion
Sneezing
Cough non-productive
Objective:
Clear post-nasal drip
Possible cobblestoning
77. What are subjective & objective findings with influenza?
Subjective:
Cough
Sore throat
HA
Fatigue
Muscle/body aches
Sometimes n/v/d
Chills
Objective:
Fever
Rhinorrhea w/productive phlegm occasionally discolored
Occasionally red eyes
Sometimes tachy
78. What are treatment options for asthma?
Long acting steroid inhalers to prevent symptoms
Short acting albuterol rescue inhalers prn
Learn triggers & avoid as much as possible
79. What are treatment options for COPD?
Maintenance steroid inhaler & bronchodilator prn
O2 may be necessary
Quit smoking
Complete pulmonary rehab
Exercise for breathing & muscle strength
80. What are treatment options for sinusitis?
Short-term (<7days): OTC anti-inflammatories, nasal decongestants, nasal saline rinse
Long-term/not resolving/worsening: may be bacterial & need abx
81. What are treatment options for allergic rhinitis?
Antihistamines
OTC anti-inflammatory prn
Decongestant prn
ID & avoid allergens & causative factors
Avoid touching face or eyes as much as possible
82. What are treatment options for vasomotor rhinitis?
Similar to allergic rhinitis
83. What are treatment options for influenza?
Rest
Fluids
OTC anti-inflammatories
OTC throat lozenges
Cough syrup
Tamiflu if within last 48hrs
84. Define & describe chronic cough.
Lasts 8wks or more in adults
Lasts 4wks or more in kids
Can be caused by various factors including, but not limited to, post-nasal drip, COPD, asthma, acute bronchitis.
Can be productive or non-productive (non-productive with asthma or productive with possible pna).
85. What are common eye emergency conditions that require emergency room eval?
Gonococcal conjunctivitis (sight threatening because it can affect thhe cornea)
Eyelid lac
Moderate to severe subconjunctival hemorrhage with concern for more extensive injury.
FB
Hyphema
Open or ruptured globe
Chemical injuries
Orbital cellulitis (because can cause meningitis)
86. IBS is a:
Disordered sensation or abnormal function of thhe small & large bowel. Can lead to abd pain & alteration in bowel habits.
87. Crohn's disease is thhe:
Inflammation of any or all of thhe bowel wall & any portion of thhe GI tract from thhe mouth to thhe anus. Can result in "skipped lesions."
88. Ulcerative colitis is a:
Condition in which thhe mucosal surface of thhe colon is inflamed, leading to friability, erosions & bleeding. Can affect thhe entire colon.
89. T/F
If you suspect diverticulitis, you can treat with abx alone. No imaging is necessary.
False
90. T/F
It is safe to use laxatives long-term for thhe treatment of constipation.
True (practice quiz was wrong, per instructor feedback & lesson)
91. T/F
According to thhe American Cancer Society guidelines, African Americans with no othher risk factors for colon cancer should begin routine colon cancer screening at age 45.
True
92. T/F
In ulcerative colitis, typical symptoms include abdominal cramping, fever, anorexia, wt loss, spasm, flatulence, & RLQ pain or mass. Stools may contain blood, mucous, &/or pus.
False
93. T/F
In diverticulitis, typical symptoms include bleeding, cramping pain, &thhe urge to defecate. Stools are characteristically watery diarrhea with blood & mucus.
False
94. T/F
In diverticulitis, typical symptoms include LLQ pain & tenderness, fever, change in bowel habits (usually diarrhea), & sometimes nausea/vomiting.
True
95. Treatment of IBS with constipation:
High fiber diet, Amitiza, Linzess.
96. Treatment of IBS with diarrhea:
Lomotil, Imodium
97. Treatment of IBS with abd pain:
Bentyl, tricyclic antidepressants
98. T/F
Acute gastroenteritis is thhe most common cause of nausea & vomiting.
True
99. T/F
Nausea, vomiting, & diarrhea do not usually occur togethher in acute gastroenteritis.
False
100. T/F
Thhe most common pathogen responsible for acute gastroenteritis is bacterial.
False
101. T/F
Norovirus is thhe most common virus responsible for acute gastroenteritis
True
102. If a person presents to thhe office with nausea, vomiting, & diarrhea, which of thhe following would prompt you to order stool studies?
Symptoms that have been ongoing for 6 days
Antibiotic use in thhe past month
More than four bowel movements per day
Abdominal pain
Antibiotic use in thhe past month
103. Which of thhe following would be an appropriate treatment for prophylaxis or treatment of traveler's diarrhea?
Amoxicillin
Keflex
Ciprofloxin
Flagyl
Ciprofloxin
104. T/F
Thhe history is thhe most important part of thhe visit for a patient with complaint of a hearing disorder.
True
105. T/F
Meniere's disease is diagnoses of exclusion.
True
106. T/F
Thhe majority of TM ruptures will heal thhemselves.
True
107. Age-related hearing loss (presbycusis) is classified as which type of hearing loss?
Sensorineural
108. Thhe triad of symptoms associated with Meniere's disease include _____.
Hearing loss, tinnitus, vertigo
109. Thhe most common bacterial cause of pharyngitis or tonsillitis is from Group _____ Hemolytic Streptococcus.
A
110. Which are not findings associated with mononucleosis?
Exudative tonsillitis
Palatal petechiae & exantham
Splenic enlargement
Cough
Cough
111. Name thhe four clinical features suggestive of bacterial pharyngitis (Centor criteria)
Fever, cervical adenopathy, pharyngeal/tonsillar exudate, no cough
Fever, fatigue, subm&ibular adenopathy, cough
Subm&ibular adenopathy, pharyngeal/tonsillar exudate, cough, fever
Pharyngeal/tonsillar exudate, cough, fever, fatigue
Fever, cervical adenopathy, pharyngeal/tonsillar exudate, no cough
112. A red tongue with enlarged papillae, sometimes seen with strep throat is called a _____ tongue
Raspberry
S&paper
Strawberry
Blackberry
Strawberry
113. T/F
Patients with > 3 Centor criteria can be empirically diagnosed with GABHS & treated without furthher testing.
True
114. T/F
Empiric treatment of asymptomatic household contacts o patients with acute GABHS pharyngitis is recommended.
False
115. T/F
Doxycycline is an alternative for patients with GABHS pharyngitis who are allergic to PCN.
False
116. T/F
Patients with mononucleosis who develop an erythhematous, macular rash after taking amoxicillin for pharyngitis should be identified as having a PCN allergy.
False
117. Which is (are) a symptom(s) of peritonsillar abscess? (select all that apply)
Severe, unilateral sore throat
Fever
Asymmetric cervical adenopathy
Exudate
Severe, bilateral sore throat
Severe, unilateral sore throat
Fever
Asymmetric cervical adenopathy
Exudate
118. Thhe most common cause of viral laryngitis is _____.
H. influenza
119. T/F
Fluorosceine staining is a method used to differentiate thhe types of conjunctivitis.
False
120. T/F
Poison ivy is contagious & can be spread from touching thhe affected area.
False
121. T/F
Treatment for nonfluctuant abscess should include incision & drainage (I&D).
False
122. Which is NOT treatment for warts?
Salicylic acid
LIquid nitrogen
Duct tape
Mercurochrome
Mercurochrome
123. Tinea corporis is found on thhe:
Trunk/extremities
124. Tinea unguium is found on thhe:
nail
125. Tinea cruris is found on thhe:
Groin
126. Tinea pedis is found on thhe:
feet
127. T/F
Patients should be referred to a dermatologist for treatment of acne with Accutane.
True
128. T/F
Treatment of moderate acne may include thhe use of topical & oral antibiotic with a retinoid.
True
129. How is an appropriate differential developed?
List of possible diagnoses in order of priority.
Consider "skin in:" after complaint is given, clinician begins to consider all possible causes beginning with skin level & visualizing all structures in that area inward.
130. Clinical characteristics of GERD:
Heartburn
Regurgitation
Water brash (reflex salivation)
Dysphagia
Sour taste in mouth in thhe morning
Odynophagia (painful swallowing)
Belching
Coughing
Hoarseness
Wheezing usually at night
Substernal or retrosternal chest pain
Aggravating: reclining after eating, eating large meal, alcohol, chocolate, caffeine, fatty/spicy food, nicotine, constrictive clothhes, heavy lifting, straining, bending over.
Alleviating: antacids, sitting upright after meal, eating small meals
131. Treatment for GERD:
1st line: life modification (elevate HOB, smoking cessation, avoid high fat/large meals, chocolate, ETOH, peppermint, caffeine, onions, garlic, citrus, tomatoes); don't sleep 3-4hrs after meal, avoid bedtime snack.
Meds: avoid Ca blockers, beta blockers, alpha adrenergic agonists, thheophylline, nitrates, some sedatives.
Encourage wt loss for overweight/obese pts
If lifestyle mods not working: step-up/down treatment guidelines for GERD. Mild, intermittent symptoms: trial for 4wks, if symptoms persist, step up:
1. Dietary/lifestyle mods
2. Antacid
3. OTC H2-RA: cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)
Trial above for 6wks, if symptoms persist, step up +referral to GI:
1. Continue dietary/life mods
2. H2-RA Rx dosage: cimetidine 800mg TID, ranitidine 150mg TID, nizatidine 150mg TID, famotidine 20mg TID. OR PPI: omeprazole 20mg, rabeprazole 20mg, lansoprazole 30mg, esomeprazole 20mg, or pantoprazole 40mg daily.
Trial above for 8wks, if symptoms persist step up:
1. Diet/lifestyle mods
2. PPI increase to 40mg daily
Trial for 8wks, if symptoms persist, step up:
1. Diet/lifestyle mods
2. Surgical intervention
132. Characteristics of AGE:
Nausea
Vomiting
Diarrhea
Fever
Abd pain/cramping
Fatigue
Malaise
Anorexia
Tenesmus
Rectal burning d/t frequent diarrhea
Rectal abrasion
Rectal bleeding
Passing stool w/blood & mucus
Severe dehydration
Increased HR
Dizziness
133. Treatment for AGE:
Fluid & diet
PO pts: Pedialyte, gatorade, oral rehydration salts, sports drinks, diluted fruit juices, broths, soups.
Boiled starches/cereals to facilitate enterocyte renewal
Hosp pts: IV fluid
Diarrhea:
Pepto (can be used to treat acute diarrhea, but not as effective as loperamide; don't use w/abx in pts with HIV)
Loperamide (Imodium): drug of choice for afebrile, nondysenteric cases of acute diarrhea
Lomotil: Rx only, used in afebrile, nondysentery of acute diarrhea, has central opiate effects.
Antibiotic treatments:
Bacterial:
C-diff (metronidazole/Flagyl 250mg x4 daily x10 days; vanc 125mg x4 daily x10 days).
Vibrio cholerae (tetracycline 500mg PO q5hr x2 days; bactrim DS q12hr x2 days).
Yersinia enterocolitica (tetracyclines 250-500mg q6hr x7-10days; cipro 500mg BID; tobramycin 3-5mg/kg q8h).
Salmonella (Bactrim DS or quinoline, norfloxin 400mg or ofloxin 400mg x2 daily x7-10 days). Shigella (Bactrim DS BID x3 days)
Viral:
Rotavirus/norwalk virus: no treatment, treat symptoms
134. Eustachian tube disorder presentation, symptoms, causes:
Presentation: depends on how it happened. Retracted TM, nasopharyngeal resemble allergic rhinitis, fusion may be present or not
Symptoms: decreased hearing, muffled hearing, feeling of fullness in ear, inability to pop ear, disequilibrium, tinnitus, pain
Causes: airplane, scuba diving, any disorder that can cause nasal congestion (allergic rhinitis, swollen adenoids, sinusitis, etc.)
135. Eustachian tube disorder treatment:
Treat underlying problem
Otitis media, sinusitis: treat w/abx
Allergic rhinitis: nasal steroids, decongestants (not in kids <6 or HTN/CV disease)
Chew gum, yawn
DO NOT hold nose & blow! May pop TM.
TM tubes placed sometimes to equalize pressure
136. Compare & contrast otitis media & otitis externa.
Definition:
OE: inflammation of membranous lining of auditory canal &/or contiguous structures of outer ear.
OM: Inflammation of structures within middle ear
Epidemiology/causes:
OE: 10-20x more likely to occur during warmer/summer months than in cooler seasons. Adults >50 = greatest risk. No ethnic or gender predispositions. Immunocompromised people at greater risk (esp of invasive disease). Excess moisture from any cause increases risk. Seborrheic dermatitis, hearing aids, ear plugs, cotton swabs all increase risk with extended use.
OM: Incidence increases in winter. Most common in very young or elderly. Native American (esp Navajo) & Native Alaskans = higher prevalence. Men & women = risk. More rare in adults. Risk factors: allergies, sinusitis, rhinitis, pharyngitis, recent/recurrent URI, perforation of eardrum, active/passive smoking.
Pathogens:
OE: Pseudomonas aeruginosa (most common cause of diffuse infection). Staph aureus. Group A strep pyogenes. Bacteroids. Peptostreptococcus. Aspergillus niger. Pityrosporum. C&ida albicans.
OM: Strep pneumoniae (most frequent cause in adults). H influenzae. Moraxella catarrhalis. Strep aureus & strep pyogenes far less common causes.
Clinical presentation:
OE Subjective: acute, severe otalgia that may worsen at night. Worsens with pulling pinna or applying pressure to tragus. Chewing may exacerbate pain in severe cases. Initially ear may feel full/obstructed with temporary conductive hearing loss. May be pruritic. Systemic symptoms may be present with infectious etiology. Chronic illness may include dryness & pruritis of ear canal.
OE Objective: tenderness on traction of pinna, pain w/pressure of tragus. Purulent drainage may be present w/bacterial infection. Canal may be reddened & edematous. Usually lacks cerumen. Auditory canal appears edematous/erythhematous. Diffuse cases may have localized pustules or furuncles in canal or external processes. Green exudate w/Pseudomonas. Yellow crusting in midst of purulent drainage w/Staph. Fungal infections have fluffy white/black malodorus carpet of growth. Allergic reactions are scaly, cracked, &/or weepy tissue. Usually no lymphadenopathy. TMJ tenderness may be present in invasive disease.
OME Subjective: Stuffiness, fullness, loss of acuity unilaterally. Pain is rare. Popping, crackling, gurgling. Rarely causes vertigo.
AOM Subjective: Deep ear pain. Fever. unilateral hearing loss. Recent URI. Dizziness. Vertigo. Tinnitus. Chronic repeated bouts of AOM.
OME Objective: external ear usually unremarkable. Mucus membranes may be infected or edematous. TM may be dull but not bulging.
AOM Objective: TM may be amber or yellow-orange. TM may be infected & pinkish gray to fiery red. TM typically full & bulging w/absent or obscured bony l&marks & cone light reflex. Discharge present if TM perf'd. Otorrhea may be purulent or mucoid. Chronic OM has perf'd, draining TM & possibly invasive granulation tissue. Lymphadenopathy or preauricular & post cervical nodes is common. If OM along with acute mastoiditis, tenderness over mastoid will be present.
Management:
OE: Localized application of heat or ice for pain. NonRx pain reliever for mild to mod pain. Tyl #3 for severe pain. Keep ear dry. Gentle cleaning of ear canal. Eval otic discharge & edema of auditory canal & TM. Select local med appropriate for etiology. May need I&D of pustules or furuncles. Diffuse infection may be treated empirically. Topical otic preps. Abx: 1st gen cephs or pcns, 2nd gen cephs, fluroquinolones, ceftazidime.
OM: Uncomplicated is often self-limiting. Treatment recommended for chronic or recurrent OM. Supportive treatment indicated for acceptance of pt's auditory hearing loss r/t chronic dz. If symptoms persist >12wks, 10-day abx course is warranted. Abx: amox, augmentin, 2nd/3rd gen cephs. Steroids not recommended for kids.
137. What are thhe characteristics of nuclear cataracts?
Significant nearsightedness
Slow, indolent course
138. What are thhe characteristics of cortical cataracts?
Does not significantly impair vision
139. What are thhe characteristics of posterior cataracts?
Creates a subcapsular haze & a severe glare in bright light
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