NR 510/AANP Study LATEST,100% CORRECT

NR 510/AANP Study LATEST Cardiac • Know S3 what does it mean o Indicative of CHF. Occurs during early diastole, aka ventricular gallop or S3 gallop. Sounds like Kentucky. Considered abnormal id occurs after the age ...

NR 510/AANP Study LATEST Cardiac • Know S3 what does it mean o Indicative of CHF. Occurs during early diastole, aka ventricular gallop or S3 gallop. Sounds like Kentucky. Considered abnormal id occurs after the age of 35. May be normal in children or young adults if there is no signs or symptoms of heart disease. • Know S4 it is a sign of what? They describe a patient. o Sounds like Tennessee. Caused by increased resistance due to a stiff left ventricle, usually indicates LVH. Considered a normal finding in some elderly due to thickening. Occurs during late diastole, also called the atrial gallop or atrial kick. Best heard at the apex or apical area, using the bell of the stethoscope. • A murmur that is loud and heard with your scope plus thrill is 4. A loud murmur that you don’t need a scope for is 6 • They tell you a systolic murmur one that radiates to the neck ( aortic stenosis) and one the radiates to the axilla (mitral regurgitation) • How do you rule out AAA -US gold standard in 65 and older especially if they smoke o Order and abdominal ultrasound and CT • You have a patient with HTN and osteoporosis what medication do you put them on for HTN o Thiazides diuretics. Has favorable effect with osteopenia/osteoporosis. o Ex: hydrochlorothiazide, chlorothalidone, indapamide • HTN drug for DM with neuropathy- o ACE (end in pril) or ARB (end in sartan) • You have a patient that on eye exam you notice copper and silver arterioles AV nicking what else do you assess them for o HTN • You have an elderly patient with ISH BP log what medication do you start? o CCB (end in pine) • PAD: o Smoking and hyperlipidemia with complaints of pain with ambulation, aka intermittent claudication, that is relieved by rest instantly. Atrophic skin changes may occur (shiny and hyperpigmentated ankles that are hairless and cool to touch). • PAD pt what is treatment? o exercise • PAD what test? o brachial index • Know chronic venous insufficiency o -Edema, thick skin discolored • Test you do for stable angina o Stress test. • Mitral area o Aka apex or apical area of the heart o 5h ICS =, midsternal line and slightly medial to the midclavicular line • Aortic area o 2nd ICS t the right side of the upper border of the sternum o Also described as the second ICS by the right side of the sternum at the base of the heart • Know Systolic and Diastolic Murmur was asked about heart murmur with high pitch holosystolic and the other one is mid systolic. o MR ▪ Panasystolic (holosystolic murmur) ▪ Heard best at the apex of the heart or the apical area ▪ Radiates to the axilla ▪ Loud blowing high putched murmur o AS o MS o AR ▪ Midsystolic ejection murmur ▪ Heard best at the second ICS at the right side of the sternum ▪ Radiates to the neck ▪ Harsh or noisy murmur ▪ Pts should avoid physical extertion, as there is an increased risk for sudden death ▪ Low pitched diastolic rumbling murmur ▪ Heard best at the apex of the heart or the apical area ▪ Also called an opening snap ▪ High pitched diastolic murmur • Best heard at the second ICS at the right side of the sternum • High pitched blowing murmur • Question about Grade III/VI Murmur: (Loud murmur easily heard) o Grade III murmur: loud murmur that is easily heard once the stethoscope is placed on the chest o Grade VI murmur: murmur is so loud that it can be heard even with the stethoscope off the chest, thrill is palpated. • Know the difference between Peripheral Arterial Disease and Chronic Venous Insufficiency. o CVI affects the lower extremities, due to venous reflux or obstruction. Symptoms include spider and varicose veins, leg pain and swelling, and changes to the color of the skin. Affected areas may become inflamed and irritated, with development of venous ulcers. • Question about JVD causes? o Right sided heart failure (abdominal fullness, dependent edema, hepatomegaly), pulmonary hypertension, tricuspid valve stenosis, constrictive pericarditis, cardiac tamponde • Know Bacterial endocarditis (There was a pt. with gradual onset of fever, hemorrhages on nail beds, painful raised red nodules) Osler’s nodes o Fever, chills, and malaise that is associated with a new murmur and abrupt onset of CHF. Present with skin finding on fingers/hands and toes/feet. These are subungual hemorrhages (splinter hemorrhages on the nailbed), petechiae on the palate, painful violet colored nodes on the fingers or feet (osler nodes), and tender red spots on the palms/soles (janeway lesions). • Questions about carotid bruit signs can signifies what? o narrowing of the carotid GI • Review seriology sample questions to learn types of hepatitis. o IgG-gone. Due to antibodies present, immune, due to vaccine. Not infectious o IgM-has infection. Pt is contagious. No immunity yet o HBSAg-screening test for Hep B. If positive, patient is positive and is infectious, wither an acute infection or chronic hep B. o Anti-HBs- antibodies present and is immune. May be due to either past infection of vaccination o HbeAg-indicates active viral replication. May be highly infectious. o Anti-HCV-screening test for hepatitis C. positive does not always mean that the patient has recovered from the infectionand has developed immunity. It instead indicate current infection. If positive order HCV RNA or HCV PCR to rule out hronic infection. Ifi positive patient has hep C. • High triglycerides increase the risk of o pancreatitis • You have a pt with chronic Hep C what will be high the AST or ALT or Both? o Both are elevated due to chronic damage • First line tx GERD o H2 blocker (ranitidine) • Hep serology you have to tell them what they have see Hollier notes o See above • You have a positive psoas maneuver and it is positive. What does this mean? o Used for acute appendicitis or suspected retropertitoneal area acute process (ie ruptured ectopic pregnancy). Flex hip at 90 degrees, ask patient to push against resistance (examiners hand) and to straighten the leg. Supine position • Rovsing sign o Deep palpation of the left lower quadrant of the abdomen results in referred pain to the right lower quadrant • Pt. with GERD and Barrett’s esophagus (white male greater than 50, with long term GERD): o Refer to Oncologist • Question about Hepatitis B active Immunology. • Question about pyloric stenosis (Hint is non bilious vomiting, olive like firm mass palpated on right upper quadrant) • Common causes of GERD. Options are (Histamine blocker, BB, CCB, cant remember the last one) o Long term use of OTC antacids, H2 blockers, chronic NSAID use, aspirin, or alcohol • Increase in triglyceride can cause? o Pancreatitis • First line treatment for Zollinger-Ellison Syndrome o Gastrinoma located on the pancreas or the stomach, secretes gastrin, which stimulates high levels of acid production in the stomach. End results is the development of multiple and severe ulcers in the stomach and duodenum. Complains of epigastric to mid abdominal pain. Stool may be tarry color. o PPI (omeprazole) Skin • • • • • • What is honey crusted lesions how do you treat o Impetogp. Fragile bullae. Puritic. o Tx include Cephalexin, dicloxcillin o If PCN allergy, azithromycin (macrolides), clindamycin o If few lesions with no bulla, may use topical 2% muprorocin ointment, aka bacitratin Actinic keratosis precursor to SCC look up in Leik how it presents o Older to elderly adults complains of numerous dry round and red colored lesions with a rough texture that does not heal. Lesions slow growing, most common locations are sun exposed areas such as the cheeks, nose, face, neck, arms, and the back; highest risk if light colored kin, hair, and/or eyes, a precancerous lesion of SCC. Early childhood hx of frequent sunburns places person at higher risk. o Tx with cryotherapy for small number of lesions. With larger numbers, fluorouracil cream 5% (%-FU cream) a topical antineoplastic agent is used over several days. Rosacea o Kight skinned adult to older patient with celtic background (irish, Scottish, English) complains of chronic and small acnes-like papules around the nose, mouthm and chin. Patient bluses easily. Usually blond or red haired and has blue eyes, o tx with metronidazole gel first, then may use azelaic acid topical gel or low-dose tetracycline or minocycline given over several weeks. How do you treat shingles? o acyclovir Older adult with induration that has been there awhile what do you do? o Bx it Basal Cell Cancer o No treatment options. More common in fair skinned individuals with long term daily sun exposure. Important risk factor is sever burns as a child o Characteristics: Waxy, pearly, telangiectasia, ulcer center lesion that does not heal. Can be white, light pink, brown, or flesh colored. May bleed easily with trauma. • Actinic Keratosis: Question about description (Scaly red to yellow located in sun exposed area • Melanoma question: Know ABCDE o Dark colored moles that may be puritic. Lesions may be located anywhere in the body including retina. Risk factors include family hx of melanoma, extensive/intense sunlight exposure, blistering sunburn in childhood, tanning beds, high nevus count/atypical nevus, and light skin/eyes. If in the nailbeds, fungal melanoma, may be very aggressive. o A (asymmetry) o B (Border irregular) o C (color varies in same region) o D (diameter >6mm) o E (enlargement or changes in size) • Subungal Hematoma o tx: Make a hole and drain the blood • Tx for moderate acne o Use prescription topicals (benzamycin) plus oral tetracycline (category D) or minocycline, or doxycline. o Tetracyclines (end in -line) can be given for acne startng at about age 13. Do not give tetracycline during pregnancy or children under age 13 o Certain oral contraceptives (desogen, Yaz( may be indicative for acne treatment. • Review your skin issues for adult and kids. Question about Rubeola (Koplick) o Measles: kopolic spots are small white round spots on a red base on the buccal mucosa but the real molars o Scabies: very puritic, especially at night. Swepenoginous rash on the interdigital webs, waist, axilla, penis. o Scarlet fever: sandpaper rash with sore throat(strep throat) o Tinea versicolor: hypopigmentated round to oval maculr rashes. Most lesions on upper shoulders/back. Not puritic. o Pityriasis rosea: christmas tree patter rash, rash on cleavage lines). Herald patch largest lesion, appears initially. o Molluscum contagiousm: smooth papules 5 mm size that are dome shaped with central umbilication with a white plug. o Erythema migranes: red target lesions that grow in size, some central clearing. Early stage of lyme disease. o Meningococcemia: purple colored to dark red painful skin lesions all over the body. Acute onset high fever. Headache, LOC changes, rifampin prophylaxis for close contacts. Life threatening and reportable o Rocky mountain spotted fever: rickettsia ricketsii from tick bite. Red spot like rashes that first break out on the hand/palm/wrist and on the feet/sole/ankles. Acute onset of high fever. severe headaches. Myalgia. Life threatening and reportable. o Mongolian spots: blue to black colored patches or stains along the lumbosacral area. May be mistaken for brusies. Usesuallyfades by age 2 to 3. o Milia: aka malaria or prickly heat. Multiple white 1-2 mm papules located mainly on the forehead, cheeks, and nose. Due to retention of sebaceous material and keratin. Spontaneous resolution. o Erythema toxicum neonatorum: small pustules (whitish yellow color) that are 1 to 3 mm in size and surrounded by a red base. Erupts during the second to the third day of life. Located on the face, chest, back, and extremities. Lasts from 1to 2 weeks and resolves spontaneously. o Seborrheic dermatitis: aka cradle cap. Excessive thick scaling on the scalp pf younger infants. Treated by softening and removal of the thick scales on the scalp after soaking scalp for a few hours with vegetable oil or mineral oil. Self limiting, resolves spontaneously within a few months. o Café au lait spots: flat light brown to dark brown spots freater rhan 5 mm. if 6 or more spots larger than 5mm (0.5 cm) in diameter seen, rule out neurofibromatosis or von Recklinghausens disease (refer to pediatric neurologist) o Port wine stain: nevus flammeus. Neonates with pink to red flat stain like skin lesion located on the upper and lower eyelids or on the V1 and V2 branches of the trigeminal nerve. If located here, refer to pediatric ophthalmologist to rule out congenital glaucoma. Blanches to pressure. Irrefulr in size and shape. Large lesions on half of the facial area may be a sign of trigmenal nerve involvement and sturge-weber syndrome. Lesion does not regree and grow with child. Can be treated with pulse-dye laser therapy. o Hemangioma: raised vascular lesion ranging in size from 0.5 to 4.0 cm that are bright red in color and soft upon palpation. Usually located on the head and neck. Lesion grows during the first 12 months. Watchful waiting, as majority involute spontaneously. Can be treated with pulse dye laser. o Hand foot mouth disease: multiple small blisters appear on the hands and the feet. Small ulcers are inside the mouth, throat, tonsils, and the tongue. o Varicella: generalized rash in different stages; new lesions crop daily. Papules to vesicles to pustules to crusts. Pruritic. Very contagious. o Seborrheic keratosis: soft wart like lesions that appear “pasted on’, Mostly seen on the back/trunk. Benign. Seen in elderly o Senile actininc keratosis: secondary to sun exposure; potential for malignancy. Precurser to SCC • How do you treat a skin fungal infection o Infection of the superficial keratinized tissue (skin, hair, nails) by tinea yeast organism. tinea yeast organisms are classified as dermatophytes. Peds o Gold standard lab includes fungal culture. KOH slide microscopy reveals pseudohyphae and spores o Tx includes OTC topicals such as azoles and allylamines ▪ OTC azoles (clotimazole-lotrimin, ,miconazole-monostat) ▪ Prescription topical azoles: terconazole (terazol cream) ▪ OTC allyamines (terbinadine (Lamisil) or naftifine cream (naftin). • What puts a new born at high risk for hyperbilirubinemia o cephalohematoma • Tanner stage III female o Breast and areola. One mound • 14 yo boy cc of bony mass on anterior tibial tubercle o osgood-schlatter ▪ common cause of knee pain in young athletes. Caused by overuse of the knee. Reperitive stress on the patellar tendon by the quadriceps muscles causes pain, tenderness, and swelling at the tendons insertion site. Most common during rapid growth spurts in teenage males. ▪ Tx: rice, avoid aggravating activities or sport will typically reduce/resolve pain. Tylenol or nsaids as needed. May continue play depending on degree of pain • They describe a weak baby, doesn’t feed well sleeps a lot o congenital heart defect • Least likely signs of child abuse o bruise in buttocks, retinal hemorrhage or bruises on shin • ADHD question- o answer is neurobiological • First line tx of ADHD o Stimulants with behavior modifications • Coarctation of Aorta o Know that systolic BP on lower extremities is supposed to be higher compare to upper extremities. In COA case its vice versa. Look for weak radial and bounding femoral pulse • ADHD is a behavior disease • Most common cause of death in children o MVA • Question about molliscum o tx none • Peds pt has sausage like mass this is what- o Intussusception • If you have a both parents with a genetic defect what is the percentage the child will have it. o 25% • Baby is 6 days old. Has eye discharge. What is it? o STD, chlamydia • Question about what’s the common bug in children with diarrhea. o Rotaviruses, noroviruses, and adenoviruses Psy • Know how an anorexia presents o Onset usually during adolescence, irrational preoccupation and intense fear of gaining wt. marked weight loss greater than 10 percent of body weight, lanugo (face , back, shoulder), amenorrhea for three months or longer. If purging, dental enamel loss may be present. May beinge eat and purge. o Complications: osteopenia, osteoporosis, periperheral edeam, cardiac complications (arrhythmias, cardiomyopathy, hypokalemia, etc.) • Antipsychotics lead to risk of what? o obesity, DM2, hyperlipidemia, metabolic syndrome, and hypothyroidism • You put a patient on Olanzapine (Zyprexa) what do you monitor o BMI -wt check every 3 months • The most common side effect of Paxil o erectile dysfunction • You will get a young female with depression what med do you start? o SSRI (fluoxetine, paroxetine, cetaolpram, escitalopram, duloxetine, sertraline, fluvoxamine) • You have an elderly female with depression what med do you start SSRI. o Choose citalopram (celexa) as it has the shortest list of interactions • Kava Kave question- something about what not to mix it with. o Benzo (end in pam), CNS depressants or hypnotic • Which medication causes low sperm count for a patient o (SSRI) • Question about grandiosity o Bipolar • They will ask you what is MME and then they will give you a question like you are asking an elderly patient to repeat three words. What test are you doing? MME o MME is a questionare that is used to evaluate an individual for confusion and dementia (alzheimers, stroke, others) • A patient 77 yo is on benzo’s how do you get them off o wean them • Zeprexa (What lab and intervention to put in place) o Weight check, DM, glucose check a1c • MAOIs o Rarely used due to serious food and drug interaction ▪ Do not combine with SSRI or TCA (amtytriptiline, nortriptyline), wait two weeks before initiating a SSRI or tca, high risk of serotonin syndrome. ▪ High tyramine foods to avoid: beer, chianti wine, some aged cheeses, fava beans, • What drug do you give in an ACUTE anxiety attack o Benzos Gero • You have an elderly patient that has new rapid onset of confusion what are labs to check for reversible causes? o CBC, TSH, BMP and UA- the main medication that causes this is Benadryl • Sensorineural (Presbycusis) • Temporal arteritis (giant cell arteritis) o Temporal headache, one side, with tenderness or induration over the temporal artery; may be accompanied by sudden visual loss in one eye (amaraurasis fugax). Scalp tenderness of the affected side. Screening test include sedimentation rate, which will be elevated. Considered a medical emergency as it can cause blindness. • Know types of Alzheimer’s: Question about a pt. expericieng memory loss, and increase in confusion and she has a history of stroke, HTN, What type of Alzheimer. Options include o Dementia with lewy bodies: second most common cause of dementia in the US. Caused by brain deposits of lewy bodies. Pt typically experiences cisual hallucinations, cognitive fluctuations, and parkinsonism. o Vascular dementia: due to stroke or CVA o frontotemporal dementia: progressive neuronal loss involving frontal or temporal lobes. Causes poor judgment, loss of empathy, socially inappropriate behavior, lack of inhibition, inability to concentrate, mood changes, speech difficulties, repetitive compulsive behaviors. Neuro • Your patient has tremor what is first line treatment o propranolol • How do abort migraines drug? o 5 HT 1 agonists: sumatripan (imitrex). 1st rule out cardiovascular disease, do not use if hx of or signs of ischemic heart disease (MI, angina), CVA, TIA, uncontrolled HTN, hemoplegic migraines. May caue flushing, tingling, chest/neck/sinus/jaw discomfort etc. Give first dose in office to ensure patient is ok, especially if risk factors (DM, obese, males greater than 4), high lipids) as it increases risks for MI. • Prophylactic tx migraines? o Beta blocker: propranolol (Inderal) o Tricyclic antidepressant: amitriptyline at bedtime • They describe a pt with Trigemial neuralgia how do you treat? o Trigemnial neuralgia (Tic Douloutreux). Three divisions: ophthalmic (V1), maxillary (V2), and the mandibular (V3). Most cases are caused by compression of the nerve root, causing unilateral face pain. Classic case, older female c/o sudden onset of severe and sharp shooting pains on one side of her face or around the nose that are triggered by chewing, eating cold foods, and cold air. Severe lacerating (knife like pain) that last s a few seconds. o Tx: high dose of anticonvulsants such as carbamazepine (tegretol)or phenytoin (Dilantin), MRI or CT scan if young, bilateral involvement, or numbness. • Treatment of cluster HA o high dose O2 • Teen with dizziness and lateral gaze and returns to normal- this means what? o Normal • Pappiledema: increased pressure in or around the brain causes part of the optic nerve inside the eye to swell. Symptoms include fleeting disturbances in vision, HA, vomiting, combination. o Sign and symptom of ICP • Question about Pt. complaining of headache after trauma: o (Options include post concussion headache, subarachnoid hemorrhage and Subdural hemorrhage). I am confident the answer is subdural hemorrhage • Question about Migraine headache: Know the description and duration of headaches as well o S/S: throbbing, nausea, photophobia, an phonophobia. May present with scotomas (blind spots in field) or flashing lights that proceed HA. o Duration of migraine HA: can last 2 to 3 days and may become bilateral if not treated. • Question about CN 3,4,6 (EOM) o CN 3: oculomotor, CN 4: trochlear, CN 6 abducens aid in extraocular movement • Question about Romberg test and how its done: o Romberg Test: tell the patient to stand with arms/hands straight on each side and with feet together. Then instruct patient to close both eyes while standing in the same position. Positive if excessive swaying, falls down, keeps feet far apart to maintain balance. Next tell patient to hold arms straight forward and close arms an observe. Assess cerebellar system. • Essential tremor. Question about a pt. complaining about upper arm tremor that seems to be hereditary. What’s the treatment? options include (Xanax, lorazepam, topolol and cant rember the last one) o Treat with beta blocker ending in lol. Legal • I did have a question about HIPPA. Something like sharing info to a boyfriend is an example of HIPPA violation, they throw out like • Beneficence: obligation to help the patient. remove harm, prevent harm, promote good. Acting in the patients best interest. Compassionate patient care. Ex: health promotion, educating obese patient about risks for obesity and recommending weight loss, encouraging patient to stop smoking and enrolling them in smoking cessation programs. Personal level, calling surgeon to get prescription for stringer pain meds for post surgical pain. • Non- maleficence: obligation to avoid harm. Protecting a patient from harm. Example, new NP is told to suture a facial laceration, advises MD that she is not trained and therefor cant do it. NP discusses new anticancer drug that may be more effective in treating a patients cancer, NP discusses known risks vs benefits of the new drug. Patient declines treatment. • Review health promotion on APEA Heme • Your pt has as big beefy tongue they have o B12 anemia: • You have a pt on coumadin INR is 1.4 hx of DVT what do you do? o Increase it • Your pt t-score is 1.5. what does that mean – o osteopenia • How do pt present for temporal arteritis and they ask for the gold stardard o BX of artery • Anemia question, Vitamin B12 deficiency, Folate. o Do hematology questions Men’s Health • What is the first line treatment in BPH- o Terazosin (Hytrin) or tamsulosin (Flomax) which is a lapha-adrenergic antagonist • Look up how acute prostatitis presents they ask you how to treat it. 35 yo male doxi 100mg BID X 10 days and Rocephin 250mg. o Acute prostatitis: acute infection of the prostate that ascends into the urinary tract. Most common nonsexually transmitted causeis Enterobacter. If occurs under 35 years old, it is treated like gonococcal or chlamydial urethritis. S/S suddenonset of high fever and chills with suprapubic and or perineal pain/discomfort. Accompanied by UTI symptoms such as dysuria, frequency, nocturia with cloudy urine. DRE reveals extremely tender prostate that is warm and boggy. o Do questions on APEA STD • If the patient is older than 35 its not likely STD but lower urinary tract symptoms. Treat with cipro BID or Levo 4-6 weeks • They describe a patient with BV “look it up” treat with Flagyl 500mg Bid X 7 days. Do not drink ETOH o BV: caused by overgrowth of anerobic bacteria. C/O unpleasant fishlike vaginal odor that is worse after intercourse. Discharge is copious and has milk like consistency. Speculum exam reveals off white to light gray discharge coating the vaginal walls. There is no vulvar or vaginal redness or irritation. Findings include clue cells (squamous epithelial cells that have blurred edges die to the large number of bacteria on the cells surface). Wiff test after drop of KOH releases fishy odor. • They tell you your patient has strawberry cervix with green discharge. How do you treat? o Trichomonas and 2gm of flagyl (metronidazole) • If you treat gonorrhea you also treat what? And how? o Chlamydia, azithromycin 1 gram PO single dose or doxy 100 mg BID x7 days and gonorrhea treatment is ceftriaxone 250 MG IM x 1 dose • If you have an HIV pt with a TB test that reads 5mm o they ARE consider positive • They describe a pt with sypillis what lab do you draw o RPR o Syphilis: ▪ Primary: painless chancre, chancre has a clean base, well demarcated with indurated margins ▪ Secondary: Condyloma lata (infectious white papules in moist areas that look like white warts)macuopapular rash on palsm and soles that is not puritic ▪ Latent: asymptomatic but will have positive titers ▪ Tertiary: neurosyphilis, gumma (soft tissue tumors), aneurysms, valvular damage, and so on • How to treat genital warts o TCA trichloroacetic acid • Question about chlamydia what drug you give o azithromycin • Question about genital wart tx o Podofilax gel, imiquimod cream, cryo, bichloroacetic, or trichloroacetic acid • Question about treating HIV pt. with antiviral and CD4 count still less than 200. What should NP tell the pt he is qualified to be diagnosed with AIDS according to CDC Women’s Health • Know the difference between probable, possible and positive signs of pregnancy. o Probable signs: goodells sign: cervical softening (4 weeks), chadwicks sign (6-8 weeks): blue coloration of cervix and vagina, hegar’s sign (6-8 weeks): softening uterine isthmus, enlarge uterus, ballottement (seen in mid-pregnancy) when the fetus is pushed, it can be felt to bounce back by tapping the palpating fingers inside the vagina, urine or blood pregnancy tests (beta hCG), quickening: the mother feels the baby’s movement for the first time. Starts at 16 weeks. o Positive: palpation of the fetus by healthcare provider, ultrasound and visualization of fetus, fetal heart tones auscultated by health provider: 10 to 12 weeks by doppler/doptone, 2o weeks by fetoscope/stethoscope. o Presumptive: amenorrhea, N/V, breast changes, fatigue, urinary frequency, slight increase in body temperature. • Naegeles rule: subtract 3 months from the month of the last menstrual period, then add 7 days. • I had a pregnant patient in her 3rd trimester painless vaginal bleeding- what is that how do you treat o Placenta previa: Mutipara who is at the late second to third trimester of pregnancy who complains of sudden onset of bright red vaginal bleeding, light to heavy accompanied by no pain or light contractions. Uterus is soft and nontender. Tx: refer to ED. Avoid bimanual examination because it may cause hemorrhage. Abdominal ultrasound only, no intravaginal ultrasound. No rectal exams. Best rest. Avoid intercourse. If contractions given MgSO$. • Same as above but painful dark red blood. What is it and how to tx o Placenta abrupto: sudden onset of vaginal bleeding (mild to hemorrhage) with abdominal abdominal and/or back pain. Painful uterine contractions. Uterus is rigid (hypertonic and very tender). Tx: refer to ED. Initial labs CBC, Pt,PTT, blood type, crossmatch, Rh factor, abdominal ultrasound, blood transfusion. Give MgSO4 if mild contractions. Strict bedrest, deliver fetus by csection if mothers life is threatedn. Give steroids if fetus viable. • What abx do you give a preg pt for UTI answer o is nitrofuration/Macrobid • Question about contraceptive for smoker: o Ok to take minipill, progestin only pill, if younger than 35 years old and if no other contraindication. • Question about a pt. pap’s smear noted with Low Grade Squamous Intraepithelial Lesions and High Grade Squamous Epithelia Lesion noted on the report, what should NP do? o HPV testing if not done and refer for colposcopy and biopsy • Question about NP palpating right ovaries on a 1-year postmenopausal woman. o Answer is to r/o ovarian cancer start with US • Another question about who is at high risk for ovarian cancer o Women over the age of 40, obese women with BMI over 40, Women who have their first full-term pregnancy after age 35 or who never carried a pregnancy to term have a higher risk of ovarian cancer, no OC hx, family hx • High risk for ectopic pregnancy o PID r/o STDs, abortions or past trauma like surgery, tubal ligation, or previous ectopic pregnancy • Preeclampsia tx: o bed rest, laying on her side and • Question about a pregnant female at slightly above symphysis pubic and Fundal height is 32cm (above the umbilical. What should be done ? o Ultrasound if difference of 2cm or more • Coombs test= Detects presence of RH antibodies • Ovarian CA risk: o Family hx • What test needed to differentiate lesion/cyst found on a breast o Ultrasound • Do women’s health questions Pulm • Asthma first line treatment. o Short acting beta 2 antagonist metered dose inhaler: albuterol, levalbuterol, or pirbuterol • They describe a pt with TB- fatigue fever cough upper lobe infiltrates on Xray • What causes the greatest increase in RR- o Hypercapnia: increased CO2 • You suspect sleep apnea which includes everything but – o obesity, enlarge tonsils, macrognathia, and macroglossia, not microglossia • RML CXR • Chronic bronchitis description and treatment o Coughing with excessive mucus productionfor at least 3 or monthsfor a minimum of 2 or more consecutive years. Tx includes symptom manage, NSAIDS, cough medicine • Croup/Epiglottitis: Question about what condition would make you order Lateral X-ray of the neck. o Drooling, • Question about CURBS: Which of the options does not require hospitalization for pneumonia Review CURBS: It’s a criteria for pneumonia hospital admission o o Confusion (abbreviated Mental Test Score <=8) (1 point) o o Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point) o o Respiratory Rate > 30 per minute (1 point) o o Blood Pressure: diastolic < 60 or systeolic < 90 mmHg (1 point) o o Age >= 65 years (1 point) o Anything scoring above 1 requires admission • Which among the list can cause increase in respiration. o hypercapnia HEENT • What is the most common pathogen of otitis externa and how to treat o Pseudomonas, treatment is cortisporin otic drops • Webber test- o lateralization to only one ear is abnormal • They describe a bilateral allergic conjunctivas o This is a short-term condition that is more common during allergy season. Your eyelids suddenly swell, itch, and burn. You may also have a watery nose. • Retinoblastoma- look up all SS of this and what it means. Google it for an advance search they do not give you basis info o Retinoblastoma is an eye cancer that begins in the retina — the sensitive lining on the inside of your eye. Retinoblastoma most commonly affects young children o Sx include: A white color in the center circle of the eye (pupil) when light is shone in the eye, such as when taking a flash photograph. Eyes that appear to be looking in different directions. Eye redness. Eye swelling • Question about AV nicking (Arterioles pressing on vein of the eye): o Its HTN retinopathy o Also copper wire arterioles and silver wire arterioles seen in same disase • Question causes of IOP • Question about horizontal nystagmus that stops when eye is close to midline in a college student o its normal • Weber o Place the tunning for midline on the forehead. Normal finding: no lateralization. If lateralization, abnormal finding. Associated with conductive hearing loss. Example: see below o Checks CN 8: acoustic • Rhinne Test o Place the tuning for first on the mastoid process then at front of the ear. Time each area. Normal finding: air conduction lasts longer than bone conduction (ie can hear longer in front ear than on mastroid) o When BC is greater than AC, think conductive hearing loss (cerumen impaction, AOM). o Test acoustic or CN 8 • Question about someone eating, painful lump noted on the jaw that comes and go. o Options include , sialolithiasis – also Caculi or salivary stones”, is a condition where a calcified mass or silaolith forms within a salivary gland usually in the duct of the sub mandibular gland also term Wharton’s DUCT – • Study apea Orthopedic • Treatment for mild ankle sprain o RICE • Treatment for medial tibial stress syndrome- o shin splint RICE • A lot of Musculoskeletal questions: o (Anteriorly ligament which is for ACL; Apprehension test positive, • lateral epicondylitis Tx, o aka tennis elbow, gradual onset of pain on the outside of the elbow that sometimes radiates to the forearms. Pain worse with twisting or grasping movements. (opening jar, shaking hands). Tx: RICE, NSAIDS • Morton’s Neuroma description as someone has a mass or nodule on the 4th/5th toe) • Question about an 88/yr. old patient in for follow up secondary. She’s been treated with Tylenol for Joint arthritis. Her SED rate was checked after 6 weeks of treatment and it was 28. Normal range is from something to 25. How would you treat the pt. o (Do nothing, Increase Tylenol, change to NSAID, and pt. is expected to have a high SED rate due to age). I think it should be changed to NSAID cuz SED rate is a sign of inflammation, • Question about medial Tibia Stress o Overuse injury or repetitive-load injury of the shin area that includes o risk factors ▪ runners without enough shock absorption (running on cement or uneven surfaces, improper running shoes) ▪ training errors (sudden increase in training intensity and duration) ▪ running >20 miles/week ▪ hill training early in the season ▪ history of previous lower extremity injuries ▪ over-pronation or increase internal tibial rotation • Symptoms o vague, diffuse pain along middle-distal tibia that decreases with running (early stage) ▪ differentiate from exertional compartment syndrome, for which pain increases with running o earlier onset of pain with more frequent training (later stages) • Physical exam o tenderness along posteromedial border of tibia ▪ 4cm proximal to medial malleolus, extending proximally up to 12cm o pes planus o tight Achilles tendon o weak core muscles o provocative test ▪ pain on resisted plantar flexion • Nonoperative o activity modification with nonoperative modalities ▪ indications • first line of treatment and successful in vast majority ▪ techniques • activity modification o decreasing running distance, frequency and intensity by 50% o use low-impact and cross-training exercises during rehab period o regular stretching and strengthening o run on synthetic track o avoid running on hills, uneven or hard surfaces • shoe modifications o change running shoes every 250-500miles as shoes lose shock absorbing capacity at this distance o orthotics may be helpful in patients with pes planus • therapy o focus on strengthening of invertors and evertors of the calf • other o local phonophoresis with corticosteroids may be effective • Question about osteoporosis risk factors. o Options include (low estrogen level, obesity, sedimentary lifestyle, cant remember the last one) o Most common I older women, white or Asian, who are thin and with small body frames, especially with family hx. Other risk factors is chronic steroid use, low testosterone in men anorexia, bulimia, low calcium intake, vitamin d deficiney, inadaquete phsycial activity, alcoholic, high caffeine intake, smoker • Tx to prevent fracture in a pt. with low vitamin d hydroxyl, high TSH and low Hct (Option include o Calcium carbonate 600mg, vitamin d 800 IU, weightbearing exercises, no swimming is not weight bearing, but walking, jogging, biking, aerobic dance, most sports • Navicular fx don’t show up on Xray right away they will in 2 weeks • Pageants disease first line treatment- I picked surgical • Study apea Renal • How do you dx a kidney stone- o US not CT • Old lady with new onset of incontinence- you do what. o UA and culture • Know your urinalysis result ENDO • Hyper and Hypothyroidism • Question about FRUCTOSESAMINE TEST. Test for how long sugar storage in system. Options include (2-4 week, 3-8 weeks 4-6 weeks and cant remember the rest). The answer is 2-3 or 4 weeks • Do questions on DM treatment Cancer Update study • Question about pencil like stool, o descending colon CA is the answer • My COA question was about a younger male with no hx of htn whos BP was 200’s/100’s in his left arm with an audible abdominal bruit –what was his dx? o Renovascular hypertension • Dacryocystitis-how it presents o Pain, redness and swelling of the lower eyelid at the inner corner of the eye. o Excessive tearing. o Pus or discharge from the eye. o Fever o Affects the nasolacraminal duct • I had to choose the best prophylactic antibiotic for a geriatric patient who is fairly healthy, undergoing knee surgery. o cephalosporin (cephalexin, cefprozil, cefuroxime, cefaclor, ceftriaxone, cefdinir, cefixime, cefepime) • Know S&S of CHF-particulary breathing difficulties (orthopnea, etc) o New onset of dyspnea on exertion, quick wt gain and peripheral edema, nocturnal wheezing and/or cough with frothy pink sputum o Left sided heart failure=lungs ▪ Crackles, decreased breath sounds, wheezing, orthopnea, paroxysmal nocturnal dyspnea, edema, cough with pink frothy sputum o Right sided heart failure=GI ▪ JVD, enlarged liver, enlarged spleen, anorexia, nausea, RUQ abd pain, and lower extremity edema • How nasal polyps present o Symptom-producing polyps can cause nasal, airway obstruction, postnasal drainage, dull headaches, snoring, and rhinorrhea. • Addisons disease—they give a question about how they present without telling you that’s what it is and ask you what labs you expect to see- o Aka primary adrenal adrenal insuficieny causes of damage to the adrenal cortex and is an autoimmune disease. o high cortisol levels, hyperkalemia, hyponatremia serum cortisol is low in primary while ACTH is high and serum aldosterone is low. • Lichen sclerosis- o how it presents (white streaks) o white spots appear on the skin and change over time. Most commonly seen in the genital and rectal areas. Spots are shinny and smooth and can eventualy spread to patches. Skin appears thin and crinkled. • Hyperthroid-how it presents and treatment o Most common cause is grave disease, then toxic toxic multinodular goiter o Classic case, women who is 30-60 with rapid weight loss, tachycardia, tremor, irritable, mensus regular. Rapid speech and high energy. Insomnia. Bulging eyes, lid lag, conjunctival edema. May have groiter, thyrid bruit, tremor, exophthalmos (graves opthalmopathy) o Dx: thyroid ultrasound, thyroid profile o Tx: radioiodine ablation, methimazole, propylthioracil (safe for pregnant women), adjunct therapy is propranolol, calcium with vitamin D, MVI, glucocorticoids • Erysipelas-how it presents on the face o Subtype of cellulitis involving the upper dermis and superficial lymphatics that is usually caused by group a strep. o CC: one large hot and indurated skin lesion that has c;ear demarcated margins, located on the lower legs (shins) or cheeks. Accompanied by fever and chills • Auspitz sign in Psoriasis-what is it? o Pinpoint areas ofbleeding remain in the skin when the plaque is removed. • Age related changes in the elderly-I had two questions, the one was about BP or HR and you had to pick the pathophysiology about why it happens. I cant remember the other one o Increase SBP due to increased PVR (stiffer arteries) o Blunted BP response due to bararecptors less sensitive. • 3 month old infant with down syndrome, due to milk intolerance, mom started on goats milk; now has pale conjunctiva but otherwise healthy. Low HCT. What additional test would you order? o Iron, TIBC • 3 months of synthroid, TSH increased, T4 normal, what do you do? o Increase Medication • 3 ways to assess cognitive function in patient with signs/symptoms of memory loss…. o Mini mental exam: orientation, short term memory (name three unrelated objects and ask to recall later), attention and calculation (serial 7, count backwards from 100), recall, write a sentence, copy a design • 4 month old with strabismus, mom is worried…… o tell her it is normal. • 4 month old wont keep anything down, what is the main thing you look at? o Growth chart • 6 month old closed anterior fontanel. o XRAY • CAGE ACRONYM o Quick screening test for identification of alcohol abuse/alcoholism ▪ C: feel the need to “cut down” ▪ A: do you feel “annoyed” when your spouse/friend comments about your drinking ▪ G: do you feel “guilty” about your drinking ▪ E: do you need to drink “early” in the morning? (eye opener). • Definition of metabolic syndrome- o cluster of conditions that increase risk of heart disease, stroke, diabetes. • Definitive diagnosis of acute bacterial prostatitis: o urinalysis and culture! • Diagnose Trich: o wet prep • Elederly presents with atrophic vaginitis, small uterus, palpable 4x5 ovary, what do you do next? o Pelvic US • Epistaxis is most common in the area of the nose known as kiesselbachs triangle, where is this located? o Anterior septum • Grade 3 cells on pap, treatment? o Excision • Growth Plate fracture o Salter Harris Fx: Salter-Harris fractures are fractures through a growth plate; therefore, they are unique to pediatric patients. • Increased risk of ectopic pregnancy…. o Salpingitis: inflammation of the fallopian tubes. • Legg-Calve Perthes disease: o avascular necrosis of the proximal femoral head • Lipid level of 1500, increased risk for? o Pancreatitis • Low HGB, Low HCT, High MCV indicates what? o Macrocytic anemia, B12 Def • Man with BPH, prostate feels on digital exam? o Enlarged, symmetrical, smooth • Man with HTN, CAD, present femoral pulses but absent pedal…. o Arterial Insufficiency • McMurrays Sign- o Used to assess Meniscus tears or injury o Assess for a “click” either heard and/or palpated. • Lachmans o Assess for ACL (anterior cruciate ligament) injury o More sensitive than drawers sign o Positive test: excessive motion of the knee indicates laxity and or rupture of the ACL. • Newborn with foot turned in, what do you do? o Refer to orthopedist • Patient forgot to start Thanksgiving dinner and husband states she has trouble remembering tasks and trouble with organization. What is this indicative of? o Alzheimers • Pt has Barretts Esophagus, insurance no longer covers GI who was treating condition. Pt at FNP office wanting refill prescriptions. What do you do? o Refer to oncologist • Pt presents with rash on shoulder, erythematous maculopapular rash with center clearing and scaling? o Tinea Corporis • Pt presents with “bag of worms:, indicates? o Varicocele • Pt with atopic dermatitis, look for what other diseases? o Asthma • Pt with bleeding after menopause- o endometrial biopsy • Pt with hx of PID, increased rick for? o Infertility • Pt with HIV took high potency anti viral treatments and CD4 is >400, what does this indicate? o This is good. Want higher than 350 • Pt with hx of htn and stroke, now having memory loss. What does this indicate? o Vascular dementia • Pregnant teacher with exposure to 5ths disease, what risk is there to the fetus? o Fetal death and birth defects • Quick assessment of patients fall risk? o Timed Get up and Go • Rotator cuff injury presentation: o disturbs sleep, arm weakness, dull ache • Shingles near eye o immediate referral to ophthalmology • Signs and symptoms of Roseola? o High fever, pink flat or raised rash o High fever for a few days with a maculopapular rash that appears after the fever breaks. • Treatment for chronic alcoholism: o 12 step program • Treatment for Gonorrhea? o Rocpehin IM and Zithromax PO • Young female want birth control, forgets to take pills, does not want to get pregnant for at least 5 years: o IUD • few questions about T2DM and appropriate treatment, including insulin. o Study APEA • When to give a pregnant woman with negative rubella titer the rubella vaccine o After pregnancy or prior to pregnancy, but wait four weeks to get pregnant • What meds you can't take while ingesting grapefruit juice o Some statin drugs to lower cholesterol, such as Zocor (simvastatin) and Lipitor (atorvastatin). o Some drugs that treat high blood pressure, such as Procardia and Adalat CC (both nifedipine). o Some organ-transplant rejection drugs, such as Sandimmune and Neoral (both cyclosporine). o Some anti-anxiety drugs, such as buspirone. o Some corticosteroids that treat Crohn’s disease or ulcerative colitis, such as Entocort EC and Uceris (both budesonide). o Some drugs that treat abnormal heart rhythms, such as Pacerone and Nexterone (both amiodarone). o Some antihistamines, such as Allegra (fexofenadine). • Drug Interactions: o Warfarin: Sulfa(Bactrim/septra), quinolones, macrolides (erythromycin, clarithromysicn), NSAIDS, phenytoin (increased INR/bleeding) o Sidenafil (Viagra): nitrates, antifungaks (end in zole) o HG-CoA reductase inhibitors (statins): niacin, gemfibrozil, erythromycin- may cause rabdo o SSRI: st johns wort, triptans (end in tan, example is trade name imetrix), TCAs (amitriptyline/Elavil o Oral contraceptives/transdermal patch (ortho evra), nuvaring: rifampin, ampicillin, tetracycline • Bells palsy s/s o One side of face paralysis due to inflammation/swelling resulting in compression of CN 7(facial nerve). Sensation intact. Most cases resolve spontaneously from 3 weeks to 3 months o Tx: artificial tears, patch at night to avoid drying cornea, rx prednisone with taper, antiviral (acyclovir) • S/S of serotonin syndrome o Dilated pupils, sweating, fever, confusion, tachycardia, tremor • Lab test for "slapped face" o No lab test. Or maybe Human Parvovirus B 19. Aka fifth disease. Caused by virus. The facial rash looks as if the cheeks were slapped. Sore throat, slight fever, upset stomach, headache, fatigue, and itching are among other symptoms. The virus usually clears up on its own, but pain relievers may help with symptoms. • What antihypertensive meds to avoid in GERD o CCB • Cotton wool on fundoscopic exam means?? o Found in diabetic retinopathy o Also hard exudates, microaneurysms, dot and blot hemorrhages, flame shape hemorrhages • Chronic use of afrin causes... o Rhinitis medicamentosa (rebound nasal congestion or bleeding • S/S of strep a pharyngitis o Sore throat. o Fever. o Headache. o Joint pain and muscle aches. o Skin rashes. o Swollen lymph glands in the neck. • Acquired hypothyroidism o The body produces destructive antibodies against the thyroid gland that gradually destroy it. Also called Hashimotos thyroiditis • Drugs for OM and alternatives o Tympanic membrane us red, bulging, and abnormal or displaced. Decreased mobility of the flat line (most objective finding) o Tx: first line: amoxicillin PO TID x10days. If PCN allergic use macrolides. ▪ Secondary tx: augmentin, cefdinir or cefuroxime. If PCN allergic, give Biaxin or Levaquin. Only give alternative if took antibioitcs previous month or treatment failure after 3 days • Grades of HF NYHA Functional Capacity o Class 1: no limitations of physical activity by symptoms o Class 2: ordinary physical activity results in fatigue, dyspnea, or other symptoms o Class 3: Marked limitations in normal physical activity o Class 4: has symptoms at rest or with any physical activity • Wilms tumor o Asymptomatic abdominal mass that extends from the flank towards the midline. Smooth and nontender, rarely crosses the midline. Higher incidence in black female children. Peak age is 2-3. Most common renal malignancy in children. Palpate gently to avoid rupturing the renal capsules. Initial imaging test is abdominal ultrasound. • Antipsychotic drug that causes hyperglycemia o Olanzapine(Zyprexa), rispiradone (Risperdal), quetiapine (Seroquel). • Management of TG if niacin does not work o Advise patient to reduce intake of simple card, junk foods, and fried food. o Start on low fat diet o Start on fibrate: femfibrozil, fenofibrate (tricor) • one on symptoms of a person with Myasthenia Gravis o drooping of upper eyelid or muscle weakness, muscle weakness of the arms and legs • Glaucoma o Acute angle closure glaucoma: acute onset of ocular pain, halos around lights with severe nausea/vomiting, blurred vision due to increased IOP. PE: cloudy corneas with fixed mid-dialated pupils that are nonreactive to light. Reddened eyes, conjunctival injection, increased tearing. Tx: refer to ED, ocular emergency o Primary open angle glaucoma:high intraocular pressure damages optic nerve 2. Peripheral vision lost first hen central vision. • OA • RA o Aka DJD. Affects weight bearing joints (knees, hips) & hands. CE: Oldent adult to elderly c/o painful knees or hips with morning stiffness (last 30 minutes or less). Pain aggravated by cold weather, changes in weather, prolonged or overuse of affected joint. PE: joint crepitus, deformity, synovitis, swelling. Tx involves exercise, weight loss, smoking cessation, isometric exercises, Tylenol, NSAIDS o Systemic automimmune disease (women greather than men) wit symmetrical arthritis that involves multiple joints. Bouchards nodes present. Anteriour uvetitis is a complication of RA, anylosis spondylitis. Joint stiffness last longer than 30 mins. Accompaniedby systemic symptoms likefatigue, fever, normocytic anemia. Tx: systemic steroids, antimalarial (plaquenil), antimeabolites (methotrexate), biologics. • Herberdens node: ends in den so it’s the DIP • Bouchards node is PIP. Found on both RA and OA • Parkinson’s, appropriate tests for poss diagnoses. o Affects dopamine receptors o CE: elderly with bradykinesia, cogwheel rigidity, pill rolling tremor, tremor that worsens with rest, mask-like stare, slow shuffling gait. Dx: based on clinical s/s. tx: levodopa • Pagets disease of the breast: o Ductal carcoinoma in situ ▪ Chronic scaley red colored rash resembling eczema on nipple/areola that does not heal. Symptoms develop quickly, lesion enlarges and includes crusting, ulceration, and bleeding • Mononucleosis o Positive strep a test and mono spot test (herterophile antibody tst). Initatiate pcn VK. Do not use amoxicillin due to possible rash • Varus vs. valgus in knee exam: o Valgum :knock kness o Varus: Bowlegs • S/S of anticholinergics (SAD CUB) o S:sedation o A: anorexia o D: dry mouth o C:confusion and constipation o U: urinary retention o B: BPH • SRI (BAD SSRI), - B: body weight increase o A: anxiety o D: Dizziness o S:serotonin syndrome o S:stimulated CNS o R:reproductive/sexual dysfunction o I:insomnia • Apthous stomatitis o canker sore in mouth that usually resolves on its own. • Assessment for dullness on patient with ascites • INR goal on patient with DVT o INR goal between 2-3. Will have positive homasn sign: lower leg pain on dorsiflexion of the foot. • -patient with IOP of 32mmHg, what do you expect during fundoscopic exam o Enlarged cup to disc ratio, presence of hemorrhage as seen in glaucoma • Janeway lesions and Osler’s nodes for bacterial endocarditis o Janeway: tender red spots on palm and soles o Osler: painful violet colored nodes on the fingers or feet Other things to study • normal PSA levels? o Less than 4.0 ng/ml • Alpha 1 blockers like tamsulosin, silodosin, and alfuzosin help give immediate relied for BPH • Avoid antihistamines like bendaryl with older men with BPH and avoid giving anticholinergics • Bilirubin greater than 5mg/dl dx is hyperbilirubinemia in newborns • Burn classifications o First degree (superficial): red to bright red skin and tenderness/pain o Second degree (partial thickness):painful red skin, bullae (blisters), reddened/weepy skin o Third degree (full thickness): pain sensation is absent. Pale/white color, charred skin, leather-like texture. Check ABCs, aggressive fluid support, debridement • Rule of 9s: o Adult: arm 9%, chest 18%, leg 18%, head (front and back) 9% o Child: arm 9%, chest 18%, leg 13.5%, head (front and back) 18% • Oncogenci strains of HPV: 16 & !8 • Warts with HPV 6&11 • know hepatitis seriology