SARAH MICHELLE BOARD REVIEW (100% Correct Answers)

St. john's Wort supplement used for depression and mental health Ginko supplement for memory; treat altitude sickness (prevention), cerebral vascular insufficiency, cognitive disorders, dementia, dizziness/vertigo ...

St. john's Wort supplement used for depression and mental health Ginko supplement for memory; treat altitude sickness (prevention), cerebral vascular insufficiency, cognitive disorders, dementia, dizziness/vertigo, intermittent claudication, macular degeneration/glaucoma, memory loss, premenstrual syndrome, SSRI-induced sexual dysfunction, and as a vasodilator Black Cohosh supplement used for menopausal symptoms; commonly used for symptoms of menopause, premenstrual syndrome (PMS), painful menstruation, weak and brittle bones (osteoporosis) CoQ10 nutritional supplement; lipid enzyme that helps in moving electrons along electron transport chain; also acts as an antioxidant; increases mitochondrial function; levels decline with age Echinacea supplement; Derivative of the purple coneflower; prevents infection and has healing properties; used internally to support the immune system. shorten the duration of the common cold and flu, and reduce symptoms, such as sore throat (pharyngitis), cough, and fever Evening Primrose supplement; Possible interaction with antipsychotic drugs; can improve nerve damage from diabetes, used for osteoporosis; acne, eczema, pms, high blood pressure, heart health, skin health, breast tenderness, Kava Kava supplement; Stress and anxiety, sedative effects; They act much like alcohol on your brain, making you feel calm, relaxed, and happy. The plant is also thought to relieve pain, prevent seizures, and relax muscles SAM-e Depression, OA, liver disease But - can cause hypomania, hyperactive muscles, possible serotonin syndrome Saw Palmetto BPH; dietary supplement for urinary symptoms associated with an enlarged prostate gland (also called benign prostatic hyperplasia or BPH), as well as for chronic pelvic pain, migraine, hair loss Soy Isoflavones supplement ; Lipid lowering effects, acute diarrhea; symptoms of menopause (such as hot flashes) and to help prevent bone loss (osteoporosis) Valerian Root calms nerves. Avoid with liver disease; relieve anxiety, depression, and poor sleep, and also to ease menstrual and stomach cramps aphthous stomatitis inflammation of the mouth with small, painful ulcers; inside the mouth; canker sore - only topical relief Herpes A viral infection causing small painful blisters and inflammation, most commonly at the junction of skin and mucous membrane in the mouth or nose or in the genitals; vesicular in nature; painful clustered vesicles on an erythematous base Keratosis Pilaris Redness and bumpiness in the cheeks or upper arms; caused by blocked follicles; chicken bumps or chicken skin; common in children - outgrow. treated with emollients and moisturizer impetigo bacterial skin infection characterized by isolated pustules that become crusted and rupture; honey crusted lesions; caused by strep pyogenes and staph aureus bollous impetigo treat with oral antibiotics non-bollous impetigo treat with bactoban/mupirocin ointment Pityriasis Rosea Presents with a herald patch, Christmas-tree pattern. back or abdomen; self limiting brown recluse spider bite Initial bite is painless Vemon is necrotizing - reactions range from mild urticaria to full thickness necrosis. Lesion is a sinking macule, pale gray in color, slightly eroded in center, with halo of tender inflammation and hemorrhage; Lesion extends to muscle; tender, deep purple, white halo present around it with systemic symptoms rocky mount spotted fever treated the same of lyme disease - doxycycline; ALWAYS doxy - benefits outweigh the risk because mortality rate is huge. 3-5 days after initial S&S a rash will appear on the hands and soles of the feet. caused by a tick lyme disease Tick-borne disease caused by the spirochete Borrelia burgdorferi. Bulls eye lesion treat with doxy - if allergic, amoxicillin Rubeola cough, congestion, conjunctivitis; 3-5 days later a rash will appear; L in measles, L in rubeola, L in Koplik's spots; prevent with MM; very contagious =. airborne; can lead to serious complications - PNA, encephalitis and permanent brain damage; don't get preg. w/in 4 weeks of having this vax; timeline: exposure -> 1 week later, contagious -> day 10: S&S start -> day 12-13; Kopliks spots -> day 15 fever subsided/rash appears -> day 22-24 rash resolves Koplik's spots Are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. spots in the mouth that appear like tiny grains of sand surrounded by an erythematous halo on the buccal mucosa parotid gland swelling most common symptom of mumps parotitis inflammation of the parotid gland Sialolithiasis presence of salivary stones actinic keratosis a precancerous skin growth that occurs on sun-damaged skin; dry pink lesions on a sun exposed area; treat with 5-FU or cryotherapy; can lead to cancer (squamous cell carcinoma) squamous cell carcinoma malignant tumor of the squamous epithelial cells in the epidermis; scaly, ulcerated, bleeds easily Cafe au lait spots Smooth edged tan-to-brown pigmentations on the skin; hyperpigmentation of the skin; traditionally benign unless there is more than 8 which can inficate neurofibromatosis malignant melanoma Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised. ABCDE - asymmetry, boarder irregularity, color variation, diameter >6, elevation; black spots under the fingernail black lines in finger nails, endocarditis, splinter hemorrhages other signs of melanoma seborrheic dermatitis an inflammation that causes scaling and itching of the upper layers of the skin or scalp; benign basal cell carcinoma Most common and least severe type of skin cancer; often characterized by light or pearly nodules. Telangiectasia skin lesion due to permanently enlarged and dilated blood vessels that are visible; there are visible blood vessels across the lesion; shiny, waxy, pearly in nature; associated with BCC contact dermatitis An inflammation of the skin caused by having contact with certain chemicals or substances; many of these substances are used in cosmetology. topical steroids/ avoid irritant; immediate and in relation to an irritant; more localized/linear Shingles A reactivation of the chickenpox virus in the body, causing a painful rash.across a dermatome, vesciular described as burning and tingling at the site before the rash appears; Consider if reporting pain on one side of body then a few days later with a rash. REFER out if close to the eyes (risk for permanent blindness or corneal scaring; prevent with Shringrix (inactivated) unstageable pressure ulcer base of ulcer covered by slough and/or eschar in the wound bed. cannot see depth of wound bed due to presence of slouth Stage 1 pressure ulcer intact skin with nonblanchable redness; foam dressings to prevent further damage eschar on heels seen in diabetics should we remove it? as long as there is no signs of infections it should not be removed or soaked when all the lesions are crusted over when can child return to school or daycare after chicken pox Head lice Parasitic insects that live on the hair shaft and cause itching; incessant pruritic throughout the day and night; treat with permetherin - only kills the lice that are alive nits or eggs need to be combed out may need second treatment very important to wash bedding in hot wanter Molluscum contagiosum wart-like growths that look like small pimples filled with kernels of corn; impregnated or have dimples; self-limiting anthrax seen in cattle farmers; ulcerated, black and painless. treat with Cipro x2 months or tetracycline Folliculitis inflammation of the hair follicles; infection of the skin follicles and the surrounding tissue - topical treatment of choice: mupirocin and if severe oral antibiotics (PCN or Keflex) Hidradenitis suppurativa Affects area containing apocrine sweat glands or sebaceous glands; Recurrent comes and goes frequently; not related to poor hygeine, linked to genetics, obesity and smoking. treated with I&D as well as wound culture. antibiotics x 2 weeks and warm compresses rosacea Chronic skin disorder of the face with red inflamed areas appearing mostly on the nose and cheeks; erythematous facial rash that doesn't space the nose; topical flagyl lupus a chronic autoimmune disease characterized by inflammation of various parts of the body; when immune system attacks tissues causing redness, pain, swelling, and damage; erythematous facial rash that DOES spare the nose = malar rash sjogren's syndrome autoimmune destruction of minor salivary glands and lacrimal glands; leads to dry eyes and dry mouth Erysipelas sharply defined with well demarcated borders; a contagious disease of the skin and subcutaneous tissues caused by infection with streptococci organisms; redness and swelling of affected areas; treated with Keflex or PCN BCD - bactrim, clindamycin, doxyccyline purulent cellulitis treatment Keflex/ PCN non-purulent cellulitis treatement Leukoplakia thickened, white, leathery-looking spots on the inside of the mouth that can develop into oral cancer; can't scrape it off; commonly seen in those with HIV Candidiasis (moniliasis) white, cheesy, curdlike patch on buccal mucosa due to superficial fungal infection; can scrape it off Rubella Distinguishing factors: very mild symptoms, pink rash, adenopathy; Rash x 2 days swollen cervical lymph nodes and low grade fever rash started on face and spread to rest of the body; day measles AKA GERMAN MEASLES- much milder much less common than rubeola; hydration, rest, NSAIDS, Tylenol; SAFETY ALERT!! highly contagious; Pregnant women cannot be around this - miscarriage or serious birth defects most high risk 1st trimester roseola Sixth disease - 2 strains of herpes simplex rash after fever!! distinguishing factors: rose color, blanchable papules; high fever, then rash appears; when the blanch-able rash appears = no longer contagious symptomatic treatment no vaccine; high fever 103 x 3-4 days irritable and fussy fever broke today but has new rash rose pink, started on trunk, turn white when pushed on, spreading to arms, neck, legs cervical adenopathy Fifth's Disease (Erythema Infectiosum) slapped cheek lacey, net like appearance to the rash; cold for a few days - now Slapped cheek rash- starts with fever, slapped face rash, Lacey net like rash across the body and spreading mildly itchy especially at soles of feet; caused by parvovirus B19; stops being contagious when the rash appears - can return to school; stay away from pregnant women as it can cause miscarriage Coxsackie virus (Hand, foot and mouth disease) Fever x 1-2 days with sore throat painful sores on front of mouth, now with rash on hands and feet some spots look like vesicles, skin peeling; ash/ulcers start in the mouth spread to the hands and feet vesicle formation and peeling = key terms antifungals like fluconazole topical or oral depends on severity how do we treat fungal infections? tinea vesicolor fungal infection all over the body tinea barbae fungal infection of the beard enterobiasis pinworm; intensely pruritic at night; Scotch tape test early in the AM; treated with mebendazole or albendazole augmentin how to treat a dog bite Lichen Planus Benign, chronic disease that affects the skin and oral mucosa; inflammatory skin condition seen with other immune disorders such as UC, vitiligo, MG; can be brought on by stress and infection; occurs on flexor surfaces of the limbs - skin, mouth, genitals; presents as reddish purple, flat top bump that is itchy - can be Lacey and white if on mucous membranes; resolve in 6 months (self limited); treat with topical steroids for non-complicated; can prescribe antihistamines as well lichen sclerosus Inflammation and epithelial thinning of the anogenital area, predominantly in postmenopausal women. White and lacey in appearance is almost always white in appearance and is primarily found on genitalia common in postmenopausal women - affects vulva not contagious - it is a result of overactive immune system gone haywire can cause painful sex or bleeding reoccurs more often than not - primary treatment = topical steroids WORRIED ABOUT: Squamous cell carcinoma risk is accelerated Lichen Simplex Chronicus Leukoplakia with thick, leathery vulvar skin associated with chronic irritation and scratching., hyperplasia of the vulvar squamous epithelium; Skin becomes leathery or rubbery in appearance due to repetatitive scratching or rubbing what can lead to this?! Atopic dermatitis/eczema treat with topical steroids and possible antihistamines patient teaching - self inflicted amblyopia lazy eye stabismus what causes amblyopia/ 20/200 legally blind test for color blindness ishihara test thinner & lighter Retinal arteries are __ and __ in color than veins optic disc should have sharp disc margins no arteries crossing veins and recreating bulges hypertension fundoscopic exam papilledema, flame hemorrhages, copper wire arteries, av nicking diabetic fundoscopic exam cotton wool spots, blot hemorrages, micrpaneurysms and neovascularization acute angle closure glaucoma sudden unilateral eye pain, redness, dilated pupil with poor light response; eye is firm to the touch; diagnosed by tonometry; refer to ED because there is a massive increase in pressure which can lead to permanent vision loss retinal detatchment Separation of the retina from its attachments at the back of the eye. feels like a curtain is being pulled over eye sudden appearance of floaters blurred vision, flashes of lights; ER ASAP arcus senilis a narrow opaque band encircling the cornea, common in old age; gray halo Xanthelasma soft, raised yellow plaques occurring on the skin at the inner corners of the eyes; cholesterol deposits; benign in elderly but indicates need for action in younger population pterygium thin tissue growing into the cornea from the conjunctiva, usually caused from sun exposure; benign noncancerous overgrowth of conjunctiva asymptomatic other than redness; encroaches the cornea Pinguecula yellowish mass on the conjunctiva that may be related to exposure to ultraviolet light, dry climates, and dust; benign noncancerous overgrowth of conjunctiva asymptomatic other than redness; N = not crossing cornea hordeolum sty; an acute infection of a sebaceous gland of the eyelid; sudden onset, localized swelling of eyelid stye - caused by infection - staph aureus purulent drainage; warm compresses and antibiotics chalazion a nodule or cyst, usually on the upper eyelid, caused by obstruction in a sebaceous gland; sudden onset, localized swelling of eyelid blockage of a duct; warm compresses Allergic Conjunctivitis eye drainage that is serous but stringy and ropey; starts bilaterally; common lymph nodes enlarged: cervical chain Viral conjunctivitis serous drainage starting in one eye then spreading to the other; common lymph nodes enlarged: pre-auricular or submandibular Bacterial conjunctivitis pinkeye; very contagious; yellow purulent eye drainage; no lymph node enlargement; spreads from one eye to the other Cararacts clouding of the lens; trouble driving at night with absent red reflex macular degeneration progressive damage to the macula of the retina; central vision loss; lifestyle modification: put things in larger print to help them read presbyopia farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age. my arms seem to be too short. reading glasses are needed corneal abrasion common after bells palsy due to lack of lubrication of the eyes; Fluorescein staining iritis inflammation of the iris of the eye;; photophobia, decreased vision, red eye, inflammation and swelling or iris; Refer ophthalmology can lead to blindness balance, eyes, face, arm, speech, time BE FAST meaning TIA transient ischemic attack....mini stroke, no dead tissue. within 1 hour, the symptoms resolve entirely aphasia inability to understand or express speech related to wenicke or broca's area in the brain Wernicke's area receptive aphasia patient can't understand what is being said no longer be receptive of information R&W are close broca's area expressive aphasia trouble expressing themselves forming speech issues E&B are close Wernicke-Korsakoff syndrome a form of dementia found with chronic alcoholism; chronic alcoholic, vitamin B1, thiamin deficiencies cluster headache excruciating stabbing or burning sensations located in the eye or cheek; one sided headache, runny nose, same time each day, tearing of the eyes; treat with 100% oxygen and CCB tension headache pain is like a band squeezing the head Temporal arteritis a form of vasculitis that can cause headaches, visual impairment, jaw pain, and other symptoms; polymyalgia rheumatica is commonly associated with inflammatory disorder causing a lot of muscle pain 15% of patients experience this as well; one sided headache, might be some visual impairment temple pain, temple pulsing increased ESR!!!!! inflammatory markers increased; diagnosed with temporary artery biopsy. treatment: long term steroids; high safety alert due to risk for permanent blindness Hypertension headache headache in adults that is occipital/vertex- throbbing; occipital headache - typically upon awakening BIG clue!! need anti- hypertension medications; most common time of day is in the morning migraine headache a headache characterized by throbbing pain on one side of the head; nausea, vomiting, photophobia, phonophobia throbbing headache, pulsating headache aura; typical prophylaxis = educate on avoiding triggers propanolol = betablockers tripans - abortive medications; uncontrolled HTN, serotonin medications (SSRIs) - cannot receive triptans because it increases risk of serotonin syndrome Parkinson's disease A disorder of the central nervous system that affects movement, often including tremors. bradykinesia, tremor, ridigity . issue with dopmain. treated with levodopa. Brudzinski's sign flex the back of the head, causes hips and knees to flex with it due to meninginial irritation Kernig's sign a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down; doesn't allow knee it extend past 90 degree angle without pain Alzheimer's disease Goal is to slow the progression of overall loss of cognitive function. associated with Apraxia, agnosia, aphasia. assessment tool: mini-mental status exam Oh Oh Oh To Touch And Feel a great Vein Ah Heaven Remember the order of cranial nerves I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Accessory XII. Hypoglossal List the cranial nerves Some Say Marry Money But My Brother Says Big Brains Matter More what to say to remember which sensory motor or both regarding cranial nerves trigeminal Cranial nerve 5 trigeminal neuralgia characterized by severe lightning-like pain due to an inflammation of the fifth cranial nerve; severe stabbing pain in the face; starts with T = tegratol is first line choice; pain is so sever, increased risk of suicide facial nerve cranial nerve VII Bells palsy cranial nerve associated with cranial nerve VII; important to educate patient to protect the eyes with lubrication and prevent corneal abrasion Rinne cranial nerve 8; think under the pinne! mastoid bone, under the ear!!!! place on the mastoid bone; normal finding: air conduction is going to be 2x that of bone conduction A comes before B - alphabet; abnormal finding: Bone conduction is 2x longer than air conduction backwards alphabet webber cranial nerve 8; tuning fork on top of the head; Normal finding: NO LATERALIZATION can hear equally on both sides in both ears conductive hearing loss can visualize the issue; will lateralize to the bad ear; hear noise louder in the ear that is having issues sound lateralize to the bad ear! can visualize the issue: cerumen impaction, cholesteatoma. sensorineural hearing loss cannot visualize the issue. will lateralize to the good ear; hearing complaints in the left ear, right ear will be good ear; cannot physically see/visualize: Meningitis, mumps, medications, etc the sound of the tuning fork will latearlize to the unaffected or good ear in these patients Meniere's disease Nystagmus, vertigo, tinnitus, ear pressure; Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears). biggest concern: possibility for potential permanent hearing loss Depression screen PHQ-2 & PHQ-9 SSRIs first line management in depression; two main issues with these: weight gain and sexual dysfunction education point usually stop on their own without consulting us We could add a different medication to combat Side effects; can take 4-6 weeks to work no symptom relief - change dose, or further investigation dominant symptom fatigue = underlying causes such as thyroid disorder; GI symptoms are super common initially -Keep on 6 months after effective dose then taper if the patient wants to Prozac SSRI to avoid in elderly because of the long half life; don't give to people with anxiety because it can cause jitteriness paxil most sedating ssri Serotonin Syndrome All the S's - Shivering, seizures, tremors, life threatening; With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures. -Treatment: cyproheptadine (5-HT2 receptor antagonist). suicidal ideation be super straight forward new antidepressant - increases this = Educate patient the need to come in; Ask: do you have a plan? how are you going to do it/ DETAILS = ER 72 hour hold for own safety TCAs not first line depression tx; don't give to elderly - TCA tons of anticholinergic side effects atypical antipsychotics notorious for weight gain and hyperlipidemia issues get lipid profiles, blood glucose, assess weight before atypical anti-psychotic; Zyprexa and seroquel are examples bipolar disorder symptoms go through phases manic - not sleeping, impulse purchases, very excited - FLIP depressed - no ADLs, can't get out of be bipolar commonly treated with lithium, which has a narrow therapeutic range and long term side effect issues when on it long term PTSD nightmares, flashbacks, hyper-vigilance, exaggerated startle response, insomnia; an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience; treat with SSRIs seasonal affective disorder disrupts the patient circadian rhythm; depressed routinely at the same time every year; talk therapy and medications but primary treatment: exposure to more light to reset natural rhythm CYP2C19 Present in the asian population; impacts this group to metabolize pain medication taking medication appropriately but not working body cannot metabolize drug in correct way due to lack of this enzyme <200 total cholesterol level 40-60+ HDL levels <100 LDL levels <150 triglyceride levels ASCVD > 7.5% when to initiate statin therapy atorvastatin, rosuvastatin two strongest HMG CoA reductase inhibitors Rhabdomyolysis associated with statin drugs; destruction of muscle to produce myoglobin; new muscle pain after starting statin; order CK- will be 5x normal limit = stop statin; If doesn't d/c statin = acute renal failure; Key distinguishing S&S is INTENSE muscle pain Acute drug induced hepatitis associated with statins; Anorexia, nausea, dark urine, jaundice, fatigue, flu-like symptoms. Labs: Elevated LFTs - ALT (SGPT) and AST (SGOT); new jaundice, LFT's need to be drawn > 500 when should you become concerned at what triglyceride level Cullen's sign ecchymosis in umbilical area, seen with pancreatitis Turner's sign Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis JNC 8 HTN guidelines initiate BP management in >60years old; if BP >150/90; <60, CKD, diabetes <140/90 AHA/ACC HTN guidelines < 130/80 BP goal; Lifestyle modification, home BP logs in order to manage med doses ACE inhibitors "PRIL" Captopril, Enalapril, Afosiopril ACE inhibitors: always monitor renal function (BUN/Creat) and K+ - (prils) at risk for hyper-kalemia; angio-edema with this = ARB; first because they decrease cardiovascular events and mortality - all other HTN meds don't thiazides avoid in people who would not benefit from increased glucose, increased lipids, increase in uric acid -> not ideal candidate; great for osteoporosis comorbidity - stimulate osteoblasts and help body retain calcium Calcium Channel Blockers -dipine; avoid in GERD patients because vasodiltation from CCB relaxes LES which allows for stomach acid to come back up out of the stomach easier - worsening; SE: Ankle edema and headaches 10% initiate BP medications in stage 1 HTN if ASCVD risk is > ?? 150/90 According to JNC8, we start BP medications at a BP of ?? if the patient is older than 60. allows more flexibility; initiate BP medications sooner if the patient has two comorbidities : CKD, diabetes Thiazide diuretics Bad for people with increased lipids, increased uric acid, increased blood glucose levels ankle edema and headaches two of the most common side effects of CCBs thiazides and CCB first line medications for african americans new little mamas BP mediations for pregnant mamas think of this - Nifedipine, lavetalol, methyldopa BP medications safe in pregnancy Category X medications in preggos ACEs and ARBs, Statins, DMARDs (methotrexate!!) CCB Preferred BP medication in the elderly with isolated systolic hypertension Respiratory sinus arrhythmia this occurs when there are variances in heart rate upon inspiration and expiration; heart rate rises with inspiration and decreases on expiration; common in young athletes pulsus paradoxus drop in blood pressure >10 mmHg with inspiration; indicative that something is going on - cardiac tamponade, status asthmaticus heart failure diagnostic labs/tests BNP, EKG, echocardiogram Ejection fraction if heart failure on echo: 40-50 - anything <40% = HF right heart failure blood backs up into the body left heart failure blood backs up into the lungs S3 heart sound found in fluid overload also in pregnancy thiazides don't give heart failure patients these medications because it causes edema NSAIDs HF patients should avoid these - increase sodium + fluid retention = excerbation anticoagulants and metoprolol two medications that Afib patients are on; blood thinner to prevent blood clots warfarin anticoagulant that can be given for Afib -measure by looking at INR Normal INR : 1 normal INR on someone not on an anticoagulant 2-3 goal INR for someone on anticoagulants Vitamin K administer if INR extremely INR and/or if actively bleeding Base this is at the top of the heart Apex this is at the bottom of the heart S1 closer of AV valves - mitral and tricuspid S2 closer of semilunar valves - aortic and pulmonic s4 uncontrolled HTN and left ventricular hypertrophy split S2 this is Normal when you can hear it only during inspiration REFER! what do you do if you can a split S2 during inspiration and expiration the base of the heart where do we auscultate for a split S2 systolic murmurs MR PASS MVP MVP systolic murmur but you hear a click; pediatric condition: Marfan syndrome radiates to the arm pit where does mitral regurgitation radiate to? radiates to the neck where does aortic stenosis radiate to? diastolic murmurs ARMS REFER! what do you do when you discover a diastolic murmur? systolic murmurs! the only murmurs that radiate are? grade 4+ what grade murmur do we feel a palpable thrill peripheral artery disease A form of peripheral vascular disease in which there is partial or total blockage of an artery, usually one leading to a leg or arm. Legs are purple and shiny decrease blood flow pain is relieved with rest and dangling; encourage to continue exercise but take breaks PRN - pain with activity intermittent claudication pain in the leg muscles that occurs during exercise and is relieved by rest Ankle Brachial Index Comparison of the blood pressure in the leg vs. the arm; normal ratio is greater than 1; PAD <0.9; dividing BP in the artery of the ankle by the BP in the artery of the arm chronic venous insufficiency a condition in which venous circulation is inadequate due to partial vein blockage or leakage of venous valves; reddish brown discoloration to the skin, edematous. causes pooling of blood - high risk for DVTs Raynaud's phenomenon a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress; disorder that causes decreased blood flow to the fingers; precipitated by cold and stress; treat with CCB and avoiding triggers cough most predominant symptom in asthma corner stone treatment of asthma low dose inhaled corticosteroid every patient should have this as it decreases overall mortality in asthma patients heigh, age, gender three things that impact peak flow Asthma treatment ICS-LABA prn —> L-ICS daily —> ICS-Laba daily —> referral examples: budesonide-formoterol prn —> budesonide daily —> budesonide-formoterol daily Bronchodilaters all end in -terol steroids will all end in - ide or -sone FEV1/FVC ratio <0.70 How to diagnose COPD COPD S/S Dyspnea, Chronic cough, Sputum production, Wheezing/chest, tightness, Tripod-ing, Clubbed nails, Prolongued expiration , Barrel chest "Pursed lip" breathing, Hypoxemia, Hypercapnia, Polycythemia; clubbing of fingers, barrel chested, chronic cough; upon percussion of chest of a COPD patient: hyper resonant Group A COPD bronchodilators - SABA Group B COPD long acting bronchodilators - Formoterol Group C COPD LAMA group D COPD LAMA and combo drug with inhaled corticosteroid Pneumonia S/S Fever, chills, crackles, rhonchi, SOB, chest pain, (productive) cough, fremitus, myalgias, sore throat, fatigue, restlessness, lethargy, splinting, tachypnea, use of accessory muscles, decreased chest movement, pleural friction rub, mental status changes; Cough, fever, chills, rhonchi, wheezes, increase tactile fremitus macrolide, amoxicillin, doxycycline pneumonia Tx - think MAD for healthy outpatient without risk factors Respiratory fluoroquinolone like levaquin combination augmentin and macrolide pneumonia treatment with comorbidities and/or antibiotics within the last 90 days CURB 65 how do we determine if an elderly patient should be admitted? 2- maybe, 3 - definitely confusion, BP <90/60, RR >20-30, BUN >19 Age >65 what does CURB stand for ? Tuberculosis Common to be seen on the upper lobes of a CXR CD4<200 when does HIV turn into AIDS? sputum culture how do you confirm diagnosis of tuberculosis/ >5mm positive PPD for TB for HIV and immunocompromised > 10mm positive PPD for TB for immigrants >15mm positive PPD for TB general public S&S of mono and strep sore, swollen throat exudates with tonsils monospot or rapid strep test PCN VK, cephalosporin, macrolide how to treat someone with both mono and strep? complications of untreated strep Sand-paper like rash with terrible looking throat - scarlantina - untreated strep throat; SERIOUS complications rheumatic fever glomerulonephritis morbiliform rash after penicillin Still need to treat with antibiotics but cannot treat with PCN because if we give a patient with mono a PCN, it is going to cause a ?? bronchitis nagging cough that won't go away. may/may not be productive; 95% are viral caused by pertussis when do we treat bronchitis with antibiotics? allergic rhinitis recent URI 7-10 days there is a reoccurrence of symptoms pain when bending over, unilateral tooth ache; Avoid triggers! Intranasal inhaled corticosteroids such as flonase. Second line: anti-histamine like benadryl 0.5-5.0 normal TSH levels hypothyroidism if TSH is high and T3/T4 are low hyperthyroidism if TSH is low and T3/T4 are high cardiac synthroid side effects in elderly every 3-6 weeks until stable how often do we win TSH hyperthyroidism beta-blocker (propanolol) tapazole or PTU = true antithyroid this + pregnancy = PTU 1st trimester then transition to tapazole subclinical hypothyroidism high tsh normal T3&4 levels = ? recheck in 6 months, until t3 t4 levels are abnormal parathyroid - located behund the thyroid but separate from thyroid purpose of parathyroid releases parathyroid hormone- keeps phos and calcium in check (inverse relationship - one is high, one is low type I has antibodies that are destroying beta cels = insulin dependent; worry about them developing DKA; never stop insulin - EDUCATIONS - continue insulin and check for ketones Somogyi effect high blood glucose level in the morning, but there is a DIP in the middle of the night = sudden rise in the morning Manage nighttime insulin or exercise before bed? Dawn phenomenon blood glucose levels steadily increase/rise all night long increase in growth hormone and insulin needs increasing . Early morning glucose elevation produced by the release of growth hormone, which decreases peripheral uptake of glucose resulting in elevated morning glucose levels. Admin of insulin at a later time in day will coordinate insulin peak with the hormone release. 6.5 HgBA1C that shows diabetes how to diagnose diabetes HgBA1C, Fasting blood glucose, oral glucose tolerance test Vitamin B12 anemia common with metformin metformin Can be used in prediabetes GI side effects - bad diarrhea - why we start on low dose and increase gradually Max dose: 2550mg/day divided into doses throughout the day doesn't cause hypoglycemia - doesn't increase insulin production; labs to monitor: BUN/Creat and renal function, gfr <46 - cut metformin in half <30 - discontinue IV contrast - hard on the kidneys - stop x 48 hours before CT with contrast SGL2 inhibitors Invokana, Farxiga, Jardiance -FLOZIN Increase glucose excretion via urine (UTIs, Yeast) Hypoglycemia risk; all end in in flozin = cardio- protective Glipizide diabetic medication that should be avoided in the elderly due to increased risk of falls screenings for a diabetic podiatrist, ophthamologist, micro-albumin podiatrist with diabetic diabetic neuropathy and loss of sensation in feet - ulcers checked out, diabetic shoes, poor circulation to extremities preventing healing ophthalmologist in diabetics neocro- vascularization, cotton wool spots, blot hemorrhages Micro-albumin in urine (done in all diabetics PCP) - two main causes of CKD HTN and diabetes - keep an eye on kidney function >9% HgBA1C at which you need to start insulin addison's disease occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone; too little cortisol in blood S&S: hyperpigmentation (very tan) everything is low except for potassium; Could develop into crisis always carrying an emergency kit of steroids around Addisonian crisis N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Cushing's disease Hyperadrenocorticism; too much cortisol in the blood everything is high except for the potassium moon face, purple striae, truncal obesity diagnosing lupus antinuclear antibody test alone cannot dx but + steroitypical symptoms = confirm suspicions; all body systems are involved - esp the kidneys malar rash red macular lesions distributed over the forehead, cheeks, and chin, resembling the pattern of a butterfly; spares the nasolabial folds Sjogren's syndrome autoimmune destruction of minor salivary glands and lacrimal glands; pop up on face dry mouth and dry eyes - management by OTC remedies 80-100 normal MCV level (size of RBC) lead intoxication, iron deficiency, thalassemia Low MCV (microcytic anemias) - think LIT Thalassemia inherited defect in ability to produce hemoglobin, leading to hypochromia; concerned with iron overload increased intestinal absorption of iron and usually require a lot of transfusion - increases iron in blood; diagnosed by hemoglobin electrophoresis iron deficiency anemia anemia resulting when there is not enough iron to build hemoglobin/iron for red blood cells; nail pitting, pica, low iron levels, high total binding capacity - alot of availability to bind iron because of lack of iron low mcv limit whole milk in children to prevent this folte, macrocytic, B12 Macrocytic; think FAB B12 and folate alcoholic anemia B12 defiency Autoimmune destruction of parietal cells ; gastrectomy; Nerve damage causing tingling and numbness in the hands and feet, muscle weakness and loss of reflexes. Weakened bones, neurological problems. Pallor -- brown-gray fingernail and toenail discoloration. AKA Perniscous anemia ; tingling in hands or feet, dizziness, unsteady gait; beefy red tongue - glossitis and super common with this anemia sickle cell anemia a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape; sickle cell crisis causes: illness and dehydration; two interventions to prioritize: fluids and pain relief. important to give all vaccines HBsAg Antigen found on surface of HBV; indicates hepatitis B infection either acute or chronic IgM IG that means you actively have an infection IgG IG Gone - no longer have hepatitis B in system rovsing sign pain in the RLQ when the LLQ is palpated (indicative of appendicitis); think reverse = right = R for rovsing Markle sign pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing; pain in the RLQ when the patient hops on one foot. Blumberg's sign The experience of sharp, stabbing pain as the compressed area returns to a noncompressed state; rebound tenderness McBurney's point A point on the right side of the abdomen, about two-thirds of the distance between the umbilicus and the anterior bony prominence of the hip; pain at the area 2/3 of belly button and anterior illiac crest tenderness = positive Obturator sign RLQ on internal rotation of right thigh indicative of appendicitis; internal rotation at 90 degrees = abdominal pain if positive Psoas sign raises leg against resistance causes pain - place pressure on right leg and if abdominal pain = positive Murphy's sign Pain with palpation of gall bladder (seen with cholecystitis); palpate into subcostal area in RUQ - pain with inspiration = positive HIDA scan Cholecystitis - US first to rule out gall stones then a ?? ultrasound after eliciting a positive murphy's sign, we can then order ? can only be done safely if no gallstones are present in the gall bladder Safety regarding HIDA scan dislodgment into pancreatic duct = ERCP what happens if you do a HIDA stone and there are gall stones in the gallbladder? Amylase and Lipase pancreas specific labs? Chvostek's sign Cheek, facial spasm when Cheek is tapped associates with hypocalcemia; tap on patient face and the face scrunches up Trousseau's sign arm/carpal spasm associated with hypocalcemia; inflate the blood pressure cuff and draws up arm like involuntary contraction Hypocalcemia typically happens after thyroidectomy when parathyroid was nicked or moved; at risk of seizure with low calcium levels Hypercalcemia an abnormally high level of calcium in the blood; possible underlying malignancy H2 blockers Mild GERD first line treatment PPI moderate GERD first line treatment; H2 blockers not working; can lead to this with long term use: osteoporosis, B12 deficiency, Cdiff H2 blockers Cimetidine Ranitidine Famotidine Nizatidine PPIs -prazole to prevent barrett's esophagus why is it necessary to treat GERD? CCB Avoid this BP medication in GERD patients Clarithromycin, amoxicillin, PPI H.Pylori treatment. Think CAP tetracycline, flagyl, PPI, bismuth salt If triple therapy doesn't work with H.Pylori, what medications do you prescribe? AAA Pulsating mass in abdomen Rupture: ER LIFE THREATENING 45-50 years old what age to start a colonoscopy? Colonoscopy should be done every 10 years with an annual fecal occult blood test; who should start earlier and - personal history or family history colorectal cancer, inflammatory bowel disease, ulcerative colitis, abdominal radiation irritable bowel disease chronic inflammation of the bowel; no inflammation although irritable will not see elevated inflammatory inflammatory markers; ulcerative colitis and crohn's - go through remissions and exacerbation can lead to colectomy inflammatory bowel disease inflammation of the colon and small intestine; will have elevated ESR or CRP RUQ pain cholecycsitis, hepatitis, liver disease LUQ stomach pain here = pancreatitis RLQ pain appendicitis LLQ pain Diverticulitis Vanco current treatment recommendation for Cdiff celiac disease disease caused by sensitivity to gluten; gluten containing foods: anything containing wheat, rye, barely; remove gluten from diet Trichomoniasis an STD caused by a microscopic protozoan that results in infections of the vagina, urethra, and bladder; strawberry cervix - pinpoint hemorrages, which is why the cervix looks like a strawberry; treat with flagyl bacterial vaginosis An overgrowth of bacteria in the vagina; characterized by itching, burning, or pain, and possibly a "fishy" smelling discharge.clue cells present + whiff test with strong odor. flagyl is the treatment Disulfiram-like reaction Metronidazole SE if given with alcohol Gonorrhea Friable cervix too many WBC to count; often co-exists with chlamydia = doxy and rocephin. if only this, treat with rocephin (think of a lot of R's in gonorrhea and Rocephin) A sexually transmitted bacterial disease that causes inflammation of the genital mucous membrane, burning pain when urinating, and a discharge Chlamydia Friable cervix too many WBC to count; if by itself, azithromycin (A in Chlamydia, A for Azithro), if allergic = doxycycline. A sexually transmitted disease, the most common in developed countries. Often producing no symptoms, it can cause infertility, chronic pain, or a tubal pregnancy if left untreated. syphilis an STD that attacks many parts of the body and is caused by a small bacterium called a spirochete; first stage: painless cancre 3-6 weeks and goes away; second stage: rash on palms and soles (can also be seen with rocky mountain spotted fever); third stage: can develop into neuro deficit; Use RPR for screening ; confirm with FTA-ABS ; treat with IM penicillin (Bicillin) depo-provera give calcium and vitamin D supplements don't let patients use this for >5 years; increases risk for osteoporosis HcG any women of child bearing age who complains of abdominal pain, run this test Presumptive all the symptoms the patient reports subjective symptoms breast tenderness, nausea, amenorrhea probable pregnancy - positive pregnancy test. Hegar sign of pregnancy Bimanual palpation of a soft uterine isthmus between the cervix below and the uterine body above. Used before modern biochemical pregnancy confirmation became available. Chadwick sign (blue cervix) pregnancy; blue cervix Goodell's sign softening of the cervix positive side of pregnancy Think PUF!!! Palpation of the futus, Ultrasound of the fetus, and Fetal heart tones level of the symphysis pubis fundal height at 12 weeks level of umbilicus fundal height at 20 weeks 24-28 weeks screen for gestational diabetes at this time as well as give Rhogam if needed treat with PCN Group B strep during weeks 35-37 gestation action cephalosporin, amoxicillin, macrobid, PCN asymptomatic UTI in pregnant women treatment - think CAMP High levels of alpha fetal protein neurotubal defects: spina bifida; folic acid down syndrome low levels of alpha fetal protein down syndrome this population is at higher risk for alzheimers, hypothyroidism, cervical spine instability placental abruption placental abruption - more serious! placenta is separating from the inner wall of the uterus; painful, bleeding, firm uterus; only occurs in 3rd trimester; Premature separation of the placenta from the uterine wall after 20 weeks' gestation and before the fetus is delivered. placenta previa implantation of the placenta over the cervical opening or in the lower region of the uterus; light painless bleeding!!! mastitis inflammation of the breast; most commonly occurs in women who are breastfeeding Mastitis treatment Dicloxacillin - a PCN - safe to continue breast feeding; PCN alternative: clindamycin, macrolides. 1) ABX (usually cephalosporins such as cefazolin/Ancef) 2) warm compresses (use baby diaper with warm water) *increases circulation to area *usually done before and during feeding 3) empty breast completely to prevent further engorgement and problems 4) start feeding on unaffected breast *causes milk-ejection reflex to occur in affected breast 5) massage affected area to promote full release **don't STOP breastfeeding from affected side; **if mother resistant d/t ABX passing to baby, teach that if bacteria is in milk it is getting treated as well pap smear these are started at age 21, regardless of prior sexual activity; every 3 years for a normal female years; >30 - every 5 years with HPV cotesting. if abnormal = colposcopy HPV vaccine Age 11 but as early as 9 years old; Gardasil - prevents HPV 16 and 18 (cause the majority of cervical cancer); prevent the hpv that causes genital warts (TCA acid is treatment for warts) endometrial biospy bleeding after menopause - need ?? ASAP hormone replacement therapy risks: cardiovascular disease, diabetes, blood clots, etc.; SSRI that can be used to help with hot flashes and night sweats: Paxil IUD, vaginal creams, CHC supplements: ginkgo - becareful because it makes the patient more anticoagulated = easily bleeding increases risk of ovarian cancer PCOS ; insulin resistance (diabetes), hyperlipidemia, and certain types of cancer; metformin is great to prescribe. is assoicated with oligomenorrhea, obesity, hirsutism and polycystic ovaries. These patients have an increased risk for developing endometrial adenocarcinoma (unopposed estrogen and progesterone is low) and type 2 diabetes (insulin resistance) assoicated with increased LH:FSH ratio prolactin if patient comes in with galactorrhea - check this ? to rule out prolactinoma is causing galactorrhea galactorrhea the production of breast milk in a women who is not breastfeeding; milky discharge expressed from breast? Atypical antipsychotics can cause this benign prostatic hyperplasia symmetrically enlarged, rubbery prostate and patient complains of hesitancy and frequency; first line: all the zosin, alpha blockers and take first dose at bedtime; Finasteride can shrink this 4 PSA cuttoff for referral. Evaluate risk level and life expectancy - will not treat unless >10 years to live because it is super slow growing epididymitis inflammation of the epididymis that is frequently caused by the spread of infection from the urethra or the bladder; unilateral testicular pain; positive phren sign (relief with elevation); scrotum is swollen and angry. <35 years old = doxycycline or rocephin. >35 years old: levofloxacin testicular torsion a sharp pain in the scrotum caused by twisting of the vas deferens and blood vessels leading into the testicle; severe unilateral testicular pain; cremastic reflex is absent; refer Cremastic reflex involuntary contractions of the major scrotal muscle, causing the scrotum to draw closer to the body GRF, Creatinine, BUN kidney function labs RBC or WBC casts will be seen with kidney dysfunction and true damage RBC casts glomerulonephritis WBC casts pyelonephritis casts ALWAYS refer if you see these in the urine UTI urinary tract infection; treat with bactrim, cipro, macrobid match antibiotic to the patients characteristics and culture and sensitivity; Bactrim always avoid this antibiotic if patient is on coumadin new heel pain - achilles tendon rupture always educate your patient to let you know if they are experiencing this after starting a fluoroquinolone PDE-5 inhibitors very first concern: think about the heart the drugs we are going to be prescribing this Osteoporosis A condition in which the body's bones become weak and break easily. DEXA scan < -2.5; risk factors: depo provera, long term steroid use, smoking, female; prevent by taking calcium and vitamin D as well as weight bearing exercises; treated with bisphosphonates - fosamax Thiazides what medication should be used to treat HTN in someone with osteoporosis? osteopenia DEXA -1 to -2.4 rheumatoid arthritis a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked; can begin at any age, fast onset, bilateral, stiffness > 1 hour, systemic symptoms. Treat with DMARDS Methotrexate - notorious for folic acid deficiency; boutonnières and swan neck deformities Osteoarthritis Inflammation of bones and joints; degeneration of bones and joints. occurs as the patient ages, slow onset, usually unilateral, Stiffness < 1 hour, no systemic symptoms; will see joint space narrowing. Treatment: NSAIDS heberdens (DIP) and bouchards nodes (PIP) Bouchard's nodes Osteoarthritis (PIP swelling 2° to osteophytes) Heberden's nodes Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis boutonniere's deformities flexion of PIP with hyperextension of DIP swan neck deformities hyperextension of the proximal interphalangeal joints with fixed flexion of the distal interphalangeal joints; associated with chronic rheumatoid arthritis ankylosing spondylitis a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae; Bamboo spine on xray; pain starts in lower back and works way up the back into the neck; autoimmune arthritis Scaphoid fracture a break in the scaphoid bone in the thumb; fall with hands use to brace the fall; AKA Navicular fracture; won't show up right away on xray - will show up 2 weeks after initial injury. if stereotypical story + pain but neg xray - still treat. treat with thumb spica cast. Treat to prevent osteonecrosis in the wrist carpal tunnel syndrome compression of the median nerve as it passes between the ligament and the bones and tendons of the wrist. treated with steroids, rest, splint Phalen's sign Tingling, numbness, or pain in the fingers within 60 seconds of performing Phalen's maneuver, a diagnostic test for carpal tunnel syndrome; backwards prayers hands; Tinel's sign "pins and needles" sensation felt when an injured nerve site is tapped; tap the inner wrist on median nerve recreate the symptoms Morton's Neuroma inflammation of the nerve typically between the 3rd and 4th metatarsals; feel like they have a pebble in their show between the 3rd and 4th toes with numbness and tingling McMurray Test compression of the meniscus of the knee combined with internal and external rotation while the patient is face-up to assess the integrity of the meniscus lachman test application of anterior and posterior force to the proximal posterior tibia to determine the stability of the ACL and PCL; Anterior draw sign Valgus Outward angulation of the distal segment of a bone or joint, as in knock-knees; tests the ligaments Straight leg test Patient supine, passively raise patient's leg to point of pain or 90 degrees; straight leg test - positive result = symptoms are reproduced between 30-70 degrees for sciatica Squat & Rise test Tests sciatica in L4 - knee jerk diminished hill walking Tests sciatica in L5 - numnbess at great toe walk on toes Tests sciatica in S1 - walk on toes and there will be a diminished or absent ankle jerk rotator cuff tear drop arm test Drop Arm Test identifies tear and/or full rupture of rotator cuff; abduct the shoulder and then lower the arm down to the waist slowly results in arm dropping to the side if rotator cuff tear empty can test flexion and internal rotation of the shoulder followed by resistance to observe for weakening of the supraspinatus muscle; supraspinatus tear allopurinol prevention medication for gout ; huge side effect: bone marrow suppression; monitor cbc while taking; don't start during an acute attack - keep on it if they are already on it lifestyle modifications for gout no alcohol, avoid diuretics, allopurian diet treatment for acute gout attack Colcrys for severe gout attacks; strong NSAID like indocin; steroids; don't give thiazide diuretics they will increase uric acid levels diagnosis for gout high serum uric acid level Fibromyalgia chronic condition with widespread aching and pain in the muscles and fibrous soft tissue; condition where there is wide spread pain and overall sensitivity; a lot of tender point; diagnosis: pain, fatigue, waking up feeling unrefreshed, cognitive issues for >3 months; symptoms not explained by any other cause; treated with cymbalta, elavil, lyrica, flexeril; regular exercise is one of the most important things they can do to prevent S&S hallux valgus (bunion) abnormal enlargement of the joint at the base of the great toe; first metatarsal phalangeal joint; diagnose by xray; treat with braces if sever - refer out for surgery plantar fascitis inflammation of the plantar fascia on the sole of the foot; pain in the heel; occurs first thing in the morning then as the day progresses, symptoms alleviate; common in runners cauda equina syndrome compression of lower spinal cord (risk of paralysis in legs); severe low back pain in conjunction with saddle anesthesia; saddle anesthesia - numbness in the areas that would touch if; incontinence; Refer ASAP for urgent surgery; caused by severe ruptured lumbar disc De Quervain's Tenosynovitis pain in the lower thumb and wrist ; inflammation the extensor pollicis brevis and the abductor pollicis longus tendons on the side of the wrist at the base of the thumb. Can be brought on by simple strain injury, treated by bracing the thumb and wrist. Finkelstein's test is positive Finkelstein's test stretching or lengthening of the thumb tendon to assess the possibility of de Quervain's disease, or tenosynovitis of the thumb tendon; examiner will grab thumb and perform ulnar deviation top of the evidence pyramid- most reliable meta-analysis/systematic review pulling several studies that have already been done the middle of the evidence pyramid All the C's: randomized control trials, cohort studies, case control studies, cross sectional studies; actual research is being performed the least reliable in the evidence pyramid editorials/opinions - no real research Health Belief Model A theory of health behaviors; the model predicts that whether a person practices a particular health habit can be understood by knowing the degree to which the person perceives a personal health threat and the perception that a particular health practice will be effective in reducing that threat. people will not change health behaviors unless the personally believe they are at risk and want to avoid negative health consequences. predict health behavior: perceived risks susceptibility, risk severity, benefits to action, belief of consequence, cues to action, self- efficacy license what gives you the ability to practice in your state certification Documentation of having met certain standards; board exam credentials written evidence showing that a person has a right to a certain position or authority; the process you go through in order to bill medicaid, medicare, etc. massive verification process occurrence based liability insurance that is not affected by job changes, retirement, as long as active policy when you saw the patient, you are protected you have coverage while you are still employed; leave the job - loose coverage; even if patient comes back 1 year later, had insurance coverage when you saw the patient, still not covered unless you purchase tail coverage Family Systems Theory a theory that views the family as a system of interacting parts whose interactions exhibit consistent patterns and unstated rules; the family functions as a system, a cohesive unit each family member plays a role in the system lewin's change model unfreezing, changing, refreezing unfreeze before the change occurs ; figuring out what is needed for the change change - where the change actually occurs refreeze - what you do to ensure that this change stays in place and is continued transitional care model Prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up. goal: prevent readmissions and exacerbations ICD 10 code -Reports diagnoses in all clinical settings ; tells insurance what disease is being treated CPT codes Current Procedural Terminology; tests done to get to the diagnosis a history, a physical exam, a plan three components of a chart swiss cheese model systems approach to understanding errors. Declares humans are fallible and errors are to be expected even in the best organization. The holes represent opportunities for the process to fail; all about risk analysis and management: when and error happens and we go back to figure out; where the issue continually fall through the 'holes' incident to billing Billing under a licensed physician (or other health care provider).when the MD sees the patient then NP sees the patient for the same exact diagnosis later on - allowed to bill at 100% - typically NPs can only bill up to 85% State nursing practice act These vary from state to state and govern nursing practice. What sets our scope of practice board of nursing in whatever state who enforces our scope of praactice social history relationship status, who they live with, employed smoking/drug/ETOH, social supports, exercise, stressors? medicare part A hospital insurance; all in-patient needs including hospice medicare part B Outpatient care. Extends Medicare to supplemental treatments, and physicians. all outpatient needs - diagnostic tests, second opinions, medical equipment medicare part C managed care health plans offered to medicare beneficiaries under the medicare advantage program; supplemental coverage (advantage plans) dental, vision, etc medicare part D Prescription drug coverage elderly, those with permanent disabilities who qualifies for medicare federal government funds medicare BRA- budget reconciliation act first act that allowed NPs to bill; allows us to get reimbursed up to 85% for seeing a patient balanced budget act required NPs to have NPI what was the act that assigned NP an NPI number Hitech act Health Information Technology for Economic and Clinical Health Act; this mandated that we all move to electronic medical records to get paid; major incentives to switch early; meaningful use for providers: the summary and incorporate clinical decision support; (abnormal labs in red instead of black); enact PHI (protection of health information) federal and state who funds medicaid people who live below the poverty level & cannot afford insurance who qualifies for medicaid 2000 less than $? / month is considered being under the poverty level WIC Special Supplemental Nutrition Program for Women, Infants, and Children primary prevention Efforts to prevent an injury or illness from ever occurring. BEFORE the incident ever occurs/ prevention secondary prevention Efforts to limit the effects of an injury or illness that you cannot completely prevent. when we do screenings for early detection tertiary prevention actions taken to contain damage once a disease or disability has progressed beyond its early stages; after the even already happened; rehab or treatment veracity truthfulness; telling the truth fidelity faithfulness; loyalty autonomy independence; the ability for one to make your own decisions Paternalism A policy of treating subject people as if they were children, providing for their needs but not giving them rights. parent the patient; trying to decide what is best for them because you disagree with their decision Beneficence Doing good or causing good to be done; kindly action; an action that is done for the benefit of others Non-maleficence duty to do no harm Justice Respecting the rights of others and giving them what is rightfully theirs; everybody gets the same treatment native americans use shamans as healers and believe illness is a punishment Vietnamese blood loos is worse than the illness; fear labs being drawn; stop medications when they feel better africans herbal remedies and avoid eye contact as well as loud volumes; living in harmony hispanics imbalance between individual and the environment chinese disruption between yin and yang; want women to refrain from anything cold for 1 month after birth big into cupping and coining COBRA Consolidated Omnibus Budget Reconciliation Act; allows patients to continue having access to healthcare when people quit or have been fired from a job can continue the same insurance plan that they were on while they were employed but the patient is responsible for all of their premiums . Paying the previous portion + the portion that the employer was paying for as well; up to 18 months Erikson's Psychosocial Theory stage theory of psychosocial development, lifespan consists of eight dilemmas that must be solved correctly in order to solve the next dilemma validity the extent to which a test measures or predicts what it is supposed to; the actual accuracy of the result; reliability the extent to which a test yields consistent results, as assessed by the consistency of scores on two halves of the test, on alternate forms of the test, or on retesting; how often the results can be repeated genetic information non-discrimination act prohibits the use of generic information and emplyment in healthcare insurance decisions 6 months sits up unassisted 15-18months hold a spoon - 9 months stand 12-17 months walk 12 months say mama/dada 3 years copy a circle/throw a ball/ride a tricycle - 4 years draw a cross 5-6 years old ride a bicycle 5-6 months old palmer grasp disappears - 2-3 months posterior fontanelle closure ; 12-18 months anterior fontanelle closure 4-6 months strabismus clears - 2-3 years genu varum (bow leggedness) reflexes at birth stepping reflex, moro, tonic neck reflex, rooting reflex, grasp vitamin D breastfeeding infants need this supplement >15 bilirubin level that you would initiate phototherapy white pupillary reflex leukocoria; = retino-blastinoma or congenital cataract stage 2 girls; budding; puberty starts stage 2 boys; straight pubic hair; puberty starts stage 3 girls; 1 mound stage 3 boys; growth spurt/where the penis grows the most in length stage 4 girls - 2 mounds and start of the period stage 4 boys: curly pubic hairs puberty too early <8 girls <9 boys refer to endo vaginal bleeding only normal before puberty in the first few days of life anorexia lack or loss of appetite; higher risk for bone loss and heart disease; return of period and weight gain when resolved bulemia bingeing & purging of food by various means; dental erosion and GERD due to vomiting salter harris fractures fracture that occurs on the growth plate; common in pediatric long bone fractures; treated to avoid stunted growth cryptorchidism undescended testicles - higher risk for testicular cancer Mongolian spots areas of deep bluish-gray pigmentation most commonly on the sacral aspect of a newborn. flat, smooth, not painful. will resolve by age 5 acute otitis media usually associated with an upper respiratory infection and is most commonly seen in young children; infection of the middle ear; bulging inflammed tympanic membrane;2-3 days wait it out then if it doesn't resolve - amoxicillin otitis externa Infection of the outer ear (ear canal); bacterial cause: pseudomonas. drainage smells awful. treat with oxofloxacin and analgesic drops hearing loss that can lead to speech delay results of chronic otitis media cholesteatoma collection of skin cells and cholesterol in a sac within the middle ear; cauliflower like growth in the ear; refer tympanic membrane rupture The development of a hole or tear in the tympanic membrane; painful ear and then not painful and has bloody drainage coarctation of the aorta congenital cardiac condition characterized by a narrowing of the aorta; shows up at birth; higher BP in the arms, lower BP in the leges; diminished pulses in lower extremities vesicoureteral reflux backflow of urine from the bladder into the ureters; usually resolves on own spontaneously ; refer at stage 3; order a voiding cystourethrogram for confirmation fetal alcohol syndrome A group of birth defects caused by the effects of alcohol on an unborn child; thin upper lip, smooth philtrum and low nasal bridge benzoyl peroxide, topical antibiotics, oral antibiotics acne treatment turner's syndrome A genetic defect in which affected women have only one X chromosome, causing developmental abnormalities and infertility. short stature as well as a webbed neck; delayed puberty and infertility osgood schlatter Anterior Tibial tubercle pain due to micro avulsions of growth plate on the tibial tubercle where the patellar tendon inserts; pain over the anterior tibial tubercle near the tendon insertion site; common with runners; NSAIDs, ice, will outgrow keloid Thick scar resulting from excessive growth of fibrous tissue; will decrease over time hydrocele scrotal swelling caused by a collection of fluid; abnormal accumulation of fluid around the testes; can be born with it or with injury or inflammation of the testes Kawasaki disease (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. fever > 5 days, strawberry tongue, and a peeling rash. treat with high dose ASA and IVIG pyloric stenosis narrowing of the opening of the stomach to the duodenum; projectile vomiting and pyeloric stenosis - projectile vomiting, olive shaped mass; ultrasound of the mass intussusception telescoping of a segment of the intestine; jelly like stools, sausage shaped mass, think of all of S's