SCIENCE 661 AANP Study Guide Fall 2018,100% CORRECT

SCIENCE 661 AANP Study Guide Fall 2018 ENT • Allergies to PCN - use macrolides, fluoroquinolones • Blepharitis- inflammation of eyelids TX baby shampoo, warm compresses • Baby with normal exam except yellow discharge ...

SCIENCE 661 AANP Study Guide Fall 2018 ENT • Allergies to PCN - use macrolides, fluoroquinolones • Blepharitis- inflammation of eyelids TX baby shampoo, warm compresses • Baby with normal exam except yellow discharge from eyes how to you treat. • Sialolithiasis – Stones within the salivary glands or the salivary gland ducts. Painful lump on jaw that comes and goes, Sialolithiasis typically presents with pain and swelling in the involved gland; these symptoms are usually aggravated by eating or by anticipation of eating. • Otitis media- inflammation of middle ear/inner, erythema, decreased tympanic membrane mobility, distorted landmarks, displaced light reflex, moderate to severe bulging, mastoid pain, Dx pneumatic otoscopy TX analgesics acetaminophen, ibuprofen, narcotic with codeine, amoxicillin, Augmentin, omnicef, ceftin, otic drops ciprofloxacin with dexamethasone • Otitis externa- swimmers ear, P. aeruginosa, external canal producing inflammation, itching, pain, tragal/pinna pain, otorrhea, Dx culture, TX fluoroquinolone and polymyxin B cortisporin drops! • Sensorineural loss Weber test(top of head)no laterization, normal finding, does not lateralize to either ear, bilateral hearing loss, if hear better in left ear, right sensorineural loss • Conductive loss Rinne test (behind pinna)–normal finding if AC last longer than bone conduction, good ear= air conduction> bone conduction, bad ear BC>AC • Sjogren’s syndrome- chronic autoimmune disorder characterized by decrease function of lacrimal and salivary glands • Bacterial conjunctivitis- purulent (pus) exudate, initially unilateral, then often bilateral, self-limiting 5-7 days, delay treatment till 3rd day, TX eye drops or ointment polytrim, trimethoprim, polymyxin, macrolide • Viral conjunctivitis- profuse tearing, mucus discharge, burning, concurrent URI, enlarged preauricular node TX antihistamine, decongestant drops, Trifluridine in herpes conjunctivitis • Nystagmus- eye makes repetitive uncontrolled movements, decrease vision, depth perception, balance • Fluorescein strips- check for corneal abrasions, keratitis • Horizontal nystagmus- normal for eye to return to midline • Cover/uncover test- strabismus • Hirschberg test- screening test for strabismus, compare corneal light reflex • Visual field by confrontation test- test peripheral vision • Ishihara- color vision test • Fovea of macula- responsible for sharpest vision • Cones- responsible for color vision • Rods- responsible for night vision • Mononucleosis- (Epstein Barr virus) normally lymphocytosis, maculopapular rash, fever, fatigue, pharyngitis, cervical lymphadenopathy, limit sports/activity, monitor for splenomegaly hepatomegaly, Dx monospot screen for heterophil antibodies, TX ibuprofen/Tylenol, no virus infection, no Abx treatment, rehydrate, if with strep add Ceftin for 5 days • Hairy leukoplakia- caused by Epstein Barr virus Pathognomonic for HIV infection • Strep pharyngitis- strep pyongenes, cause of scarlet fever affects heart valves and kidneys, Criteria for strep tonsillar exudates, anterior cervical adenopathy, fever, sore throat, fatigue, NO cough TX PCN, amoxicillin, macrolide cephalosporin, Dx rapid strep test, CNC, monspot if mono suspected, increases mortality in community acquired pneumonia • Allergic rhinitis- clear discharge, blue tinged or pale and swollen (boggy) turbinate’s, sneezing itching nasal stuffiness TX single most effective treatment intranasal glucocorticosteroids, antihistamines, decongestants (raises BP) • Acute rhinosinusitis- inflammation of paranasal sinuses due to bacteria, viral fungal or allergic infection, Goal to promote drainage, Sx facial pain, tooth pain, purulent discharge, nasal congestion, TX wait 10 days then amoxicillin or Augmentin, if allergy, fluoroquinolones/ tetracyclines • Kiesselbachs plexus- epistaxis commonly occurs anterior, posterior nasal bleeds may hemorrhage, refer to ER • Herpes keratitis- eye pain, photophobia, blurred vision in affected eye, DX fluorescein stain, , may result in blindness, refer to ED, ophthalmology stat • Pterygium- surfers eye, yellow triangular thickening of conjunctiva, web in eye, avoid light, glasses • Cataracts- opacity in lens, difficulty with glare, halos around light, blurred vision, gradual onset of decreased night vision, red reflex disappears (Red reflex is now opaque gray instead of orange red glow) • Macular degeneration- loss of center vision, loss of visual acuity, contrast sensitivity but still have peripheral vision, may find Drusen bodies, Dx Amsler grid to evaluate central vision changes • Retinal detachment- sudden onset of shower floaters with looking thru curtain with sudden flashes of light, refer to ED • Epiglottis- life threatening infection of epiglottis and surrounding tissue, cellulitis of the epiglottis, drooling, stridor, hoarseness, head is leaned back, can’t swallow because it hurts, big eyes scared, thumbs sign enlarged epiglottis protruding from anterior wall • Cholesteatoma- affected ear hearing loss, cauliflower like mass inside middle ear, can erode bones in face, damage facial nerve CN 7 • Retinoblastoma- white reflection in child’s pupil • Vertigo- spinning or rotating common characteristic TX antivert SKIN • Prevalent Cancer males- prostate • Prevalent cancer in females- breast • Highest mortality from cancer – Lung • Highest mortality of skin cancer-melanoma • Gynecological cancer most common- uterine/endometrial • Gynecological cancer second most common- ovarian • Kolpik spots- are a prodromic viral enanthem of measles manifesting two to three days before the measles rash itself. They are characterized as clustered, white lesions on the buccal mucosa (opposite the lower 1st & 2nd molars) and are pathognomonic for measles/rubeola. • Scarlet fever, scaralatina- sandpaper textured pink rash with sore throat strawberry tongue • Fifth disease- Parvovirus B19, stages of rash, slap cheek syndrome, erythema infection, A common and highly contagious childhood ailment causing a distinctive face rash, blanches • Roseola infantum- Sixth disease, viral infection, young children, high fever rash, rash, TX bedrest, fluids, Tylenol • Kawasaki disease- high fever enlarged lymph nodes red rash in groin are, conjunctivitis, dry cracked lips, strawberry tongue, swollen hands/feet, skin peels form hands/feet, TX high dose aspirin, gamma globulin • Hand foot mouth disease- Coxsackie virus, direct contact, with nasal discharge, saliva, blister fluid, or stool, most contagious for first week, fever, severe sore throat, headache anorexia, blisters on the hands and feet, diaper area, ulcers mouth throat tonsils and tongue, pain with acidic foods, TX symptomatic treatment ibuprofen or Tylenol saltwater gargle, cold fluids • Molluscum contagiosum- poxvirus, smooth wax like, round, (dome shaped) papules 5 mm size, central umbilication with white plug, viral skin infection results in round firm painless bumps, contagious, TX resolve on own, wart medication (if near genitals in kids, suspects sexual abuse) • Acanthosis nigricans- thickening of the skin, skin pigmentation disorder (darkening) related to diabetes, colon cancer and obesity • Intertrigo –candidiasis, burning malodorous odor, maceration, located in folds, under breasts, scrotum, inner thigh, between toes TX nystatin • Urticaria- hives TX with Benadryl or Zyrtec • Actinic keratosis- rough flat, dry, erythematous papules or plaques, scaly patch of red or brown skin caused by years of sun exposure, evolving carcinoma, precursor to squamous cell carcinoma, Dx biopsy, refer to dermatology, TX topical 5 fluoracil 5-FU, cryotherapy, • Basal cell- most prevalent skin cancer, pearly domed nodule with overlying telangiectatic vessels, maybe plaque, maybe papule, may see central ulceration and crusting, deepest layer of the epidermis, Dx gold standard biopsy, TX chemo or immunotherapy • ABCDE- asymmetry, border is irregular, color variegation, diameter .6mm size greater than pencil eraser, elevation above skin level • Squamous cell- skin cancer develops in the outer layer of the skin, lower lip common location, nodule, indistinct margins, surface is firm, scaly, irregular, and may bleed easily, may metastasize • Atopic dermatitis- (eczema) itchy inflammation of the skin TX topical steroids, emollients linear formation • Contact dermatitis- allergy to something • Seborrheic dermatitis- chronic, superficial disorder, scaly patches and red skin mainly on scalp, TX rotation of prescription/nonprescription (scalp- ketoconazole/metronidazole(antifungal) shampoo, capitrol shampoo, selenium sulfide Selsun blue(adults/children) shampoo ciclopirox shampoo, topical steroid gel hydrocortisone) face hydrocortisone, ears-hydrocortisone cream, eyelids- baby shampoo, • Sebhorric keratoses- soft wart like lesion appears pasted on, seen on back and trunk, (elderly) BENIGN • Lentigines- liver spots, tan to brown colored macules on dorsum of the hands/forearms, caused by sun damage, BENIGN • Stasis dermatitis- affects lower legs and ankles due to chronic edema (PVD) • Rocky spotted mountain fever- rash on ankles/wrists, spreads to trunk, hi fever, headache, myalgia, nausea, TX doxycycline refer to ED • Cheilitis- chapped lips, lip fissures • Moderate acne- TX oral abx + topical retinoid +/- benzoyl peroxide (tetracycline + tazarotene +/- Benz Pero ….Retin topical, oral tetracycline then Accutane (isotretinoin) • Hidradenitis suppurativa – acne inversa, the skin lesions develop as a result of inflammation and infection of sweat glands. This condition features pea- to marble-sized lumps under the skin that can be painful and tend to enlarge and drain pus. They usually occur where skin rubs together, such as in the armpits, groin, and buttocks. TX doxycycline, topical abx • Postherpetic neuralgia PHN- prophylaxis is TCA-Elavil • Subungual hematoma- collection of blood underneath toenail or fingernail, TX make hole and drain the blood (trephination) • Petechia- tiny round brown/purple spots due to bleeding under skin • Cellulitis- deep tissue, gram positive, gradual course over days, TX PCN, macrolide • Erysipelas-(strept infection)- acute onset, well demarcated and above the skin, TX pcn or macrolide • MRSA- TX Bactrim or tetracyclines • Papule – solid elevated mass up to 1 cm • Macule- flat small like a freckle • Vesicle – filled with serous fluid and less than 1 cm • Bullae- fluid filled and larger than 1 cm • Xerosis- dry skin, use petroleum-based product, not lotions • Psoriasis- pruritic erythematous plaque covered with fine silvery white scales, scalp and elbows TX topical steroids • Auspitz sign – appearance of bleeding spots when scales are scraped off from psoriasis plaque • Shingles- chicken pox, reactivation of varicella zoster virus involves single dermatome, less likely several dermatomes, finding prodrome- itching burning photophobia fever headache malaise, acute phase dermatomal rash 3-4 days, unilateral, pain, possible severe, macupapular rash progresses to vesicles then pustules 3-4 days, may appear for a week, convalescent phase- 2-3 week rash resolves, pain Dx viral culture, polymerase chain reaction PCR, TX acyclovir, zostrix cream, gabapentin amitriptyline • Spider bite- TX abx on wound, cold packs nsaids • Dog bite- treat with analgesia (Tylenol, nsaids, Demerol), Augmentin/doxycycline/Bactrim, wound cleaning with soap and water, betadine, local anesthesia (lidocaine), irrigated with 2000ml normal saline, betadine, wound debridement, facial bites should be closed with sutures only, pack wound, tetanus immunization, antibiotic therapy, • I had cat, man with scratches know tx. • Lyme disease- erythema migrans, bulls eye rash, start within 72 hours of exposure, TX with doxycycline or amoxicillin, or azithromycin Dx two step test EIA and then western blot • Lupus- multisystem autoimmune disease, characterized by remission and exacerbations, affects organs, skin kidney, heart, and blood vessels, face butterfly rash, avoid sunlight exposure, photosensitivity TX refer to rheumatologist, topical and oral steroids, avoid sun and cover skin Less seen in Caucasians • Pityriasis rosea- Christmas tree pattern rash, herald patch, normally on trunk • Anthrax- TX doxycycline/ fluoroquinolones (Cipro) • Tinea versicolor- trunk and extremities sun spots • Tinea corporis-(ringworm) arms/legs or body • Tinea cruris- jock itch • Tinea capitas- skin or scalp • Tinea pedis-athletes foot • Psoriasis- cause pitting in finger nails HEART • Systolic murmurs (audible between 1st and 2nd heart sound) MR/mitral regurg (high pitch), heard at mitral area- radiates to left axilla AS/aortic stenosis (medium pitch) heard at AORTA area- radiates to neck MVP/mitral valve prolapse (midsystolic click) heard at mitral area • Diastolic murmurs—ABNORMAL ASSOC WITH AORTIC/PULMONIC VALVES (audible between 2nd and 1st heart sound) AR/aortic regurg (high pitch) heard at AORTA area MS/mitral stenosis (low pitch with bell) heard at mitral area • S1- closure of atrioventricular valves , state of systole • S2- closure of semilunar valves • S3- heard in pulmonic, sign of CHF, S3 gallop heard in pregnancy and thyrotoxicosis/ know other presentations of HF • S4 – heard in elderly not associated with heart disease, normal • Pulse deficit- apical/radial pulse taken at same time, find difference • Hypertrophic cardiomyopathy- causes sudden death in young athletes • Mitral area- 5th ICS midclavicular, apex, apical area, PMI, apical pulse • Aorta area- 2nd ICS to the right side of upper border of sternum, • Grade of murmurs 1. Barely audible, 2 faints but audible, 3 Moderately loud no thrill palpable, 4 LOUD WITH PALPABLE THRILL, 5 very loud stethoscopes off chest, thrill palpable, 6 audible without stethoscope thrill palpable • HTN- first line therapy is lifestyle modification changes, lose weight, stop smoking, reduce sodium, limit alcohol, adequate electrolytes seen in HTN- AV nicking - arterioles pressing on veins, arteries are smaller than veins, its hypertensive retinopathy, copper wire arterioles, flamed shaped hemorrhages • Raynaud’s phenomenon- America flag change of colors fingertips toes TX CCB • Coaction of aorta- narrowing of the large blood vessel that leads from the heart, systolic BP on lower extremities is supposed to be higher compared to upper extremities, in COA its vice/versa (weak radial pulse and bounding femoral pulse) CAUSED BY CONGENITAL HEART DEFECT • Peripheral arterial disease-impedance of arterial blood flow in lower extremities ankle brachial index <.90, plaque develops in in vessels due to atherosclerosis, pain with exercise, relief with rest, lack of hair growth on lower extremities, gangrene toes TX check pedal pulses, ABI test, exercise by walking, lifestyle modifications -smoking cessation, antiplatelet • Chronic venous insufficiency- and varicose veins result from venous incompetence secondary to valvular dysfunction, low extremity edema, skin discoloration, ulceration, DVT/PE are complications warm to touch, TX light exercise, stockings, weight loss, elevate legs • Jugular vein distention- right side heart fx, causes HF, pulm HTN, tricuspid valve stenosis, superior vena cava obstruction, constrictive pericarditis, hypervolemia, cardiac tamponade • Pericarditis- sharp pain, worsens laying down • Bacterial endocarditis- Endocarditis is an infection of the endocardium, which is the inner lining of your heart chambers and heart valves, Fever is the most common symptom of IE, it is often associated with chills, anorexia, and weight loss. Other common symptoms of IE include malaise, headache, myalgias, arthralgias, night sweats, abdominal pain, dyspnea, cough, and pleuritic pain [4]. Patients with IE associated with dental infection may report tooth pain or related symptoms. splenomegaly, Janeway lesions, which are red spots on the soles of your feet or the palms of your hands, Osler's nodes, which are red, tender spots under the skin of your fingers or toes, Petechiae which are tiny purple or red spots on the skin, whites of your eyes, or inside your mouth (gradual onset of fever, hemorrhages under nail beds, painful raised red nodules) Artificial heart valves. Germs are more likely to attach to an artificial (prosthetic) heart valve than to a normal heart valve. Risk factors- Congenital heart defects. If you were born with certain types of heart defects, such as an irregular heart or abnormal heart valves, your heart may be more susceptible to infection. A history of endocarditis. Endocarditis can damage heart tissue and valves, increasing the risk of a future heart infection. Damaged heart valves. Certain medical conditions, such as rheumatic fever or infection, can damage or scar one or more of your heart valves, A history of intravenous (IV) illegal drug use TX amoxicillin or macrolide • Pulsus paradoxes- also paradoxes pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. Associated with status asthmaticus • Cardiac tamponade- life threatening condition equal elevation of atrial and diastolic pressures in the ventricle and pericardial pressures as well as exaggerated inspirory decrease in arterial systolic pressure (pulsus paradoxus) and arterial hypotension • Ventricular septal defect- common heart defect most often present at birth but can occur in adults after surgery or a heart attack. It involves a hole in the wall between the heart's lower chambers, Symptoms may include a bluish tint to the skin, lips, and fingernails, along with poor feeding, poor weight gain, and fast breathing, Whole body: fatigue, inability to exercise, or sweating, Heart: murmur or enlarged heart Also common: baby feeding difficulties, blue skin from poor circulation, failure to thrive, or swelling Most holes close on their own, though many may need surgery or a catheter-based procedure to close the hole. Symptoms can be treated with blood pressure medicines or diuretics. TX Lasix, Lisinopril, percutaneous vsd closure sx, self-heal, • Digoxin toxicity- including cardiac (arrhythmia)tachycardia, irregular pulse, gastrointestinal (loss of appetite, anorexia, nausea, vomiting, diarrhea, and abdominal pain), and neurologic findings (confusion, fatigue, malaise, weakness, dizzy, headache, seizures, delirium). hyperkalemia, Vision changes (unusual), including blind spots, blurred vision, changes in how colors look, or seeing spots. Drugs interaction diuretics, Amiodarone Benzodiazepines Beta-blockers Calcium channel blockers Cyclosporine Erythromycin, clarithromycin, and tetracyclines Propafenone Quinidine, Propylthiouracil, Indomethacin, Triamterene, Amphotericin B, Succinylcholine, Herb/nutraceutical – Ephedra Dx digoxin level, electrolytes • Angina- chest pain relieved by rest • MI- chest pain not relieved by rest squeezing tightness, elephant sitting on my chest, • CHF- first line TX is ace or Arb • Cholesterol<200, HDL >40, LDL <100, Triglycerides <150 TX first line life modifications, niacin fenofibrate • Statins- side effect confusion, rhabdo-lab is CK, no grapefruit, antifungals, abxs, • Metabolic syndrome- abdominal obesity, HTN, hyperlipidemia, related to diabetes • BMI- weight/height ENDOCRINOLOGY • Hyperthyroid- Graves’ disease-, elevated t4, t3, goiter, palpitation, cardiovascular symptoms (AFIB), insomnia, menstrual irregularities, diaphoresis, heat intolerance, anxiety, night sweats, blurred vision, lid lag, photophobia, double vision, diarrhea, tremors, weight loss, exophthalmos (bulging eyes), soft hair and nails, (complications: thyroid storm (life threatening), HF, visual disturbance)long term effects- heart disease, osteoporosis, mental illness, infertility. Dx TSH, thyroid panel, antibody test TX PTU propylthiouracil, methimazole Tapazole, Radioactive iodine, RAI, BB for intial tachycardic, palpitations or tremors • Hypothyroid- Hashimoto’s thyroiditis produces antibodies to destroy thyroid gland, lethargy, weight, gain, cold intolerance, constipation, heavy menses, myalgia, muscle cramps, headaches, weakness, dry skin, coarse hair, loss of lateral eyebrows, , alopecia, hoarseness, slight impairment of menta ability, depression, decreased libido, hypersomnia, thickened tongue, delayed deep tendon reflexes, middle aged woman, constipation, intolerance to cold, menstrual irregularities, memory loss, muscle cramps, coarse dry skin, hair loss, brittle nails, bradycardia, anemia, side effect swollen fingers, hyperlipidemia, complications osteoporosis/penia, mental retardation, myxedema coma, can lead to ovulation dysfunction and infertility. Hypothyroidism and PCOS normally include increased serum free testosterone, luteinizing hormone (LH), and high cholesterol. Dx tsh, tsh with t4, order TPO’s antibody test to confirm diagnosis, TX Synthroid 25-50mcg, half for elderly recheck 6-8 weeks • Hypothyroid- elevated TSH >.5 t4, t3, low • Subclinical hypothyroid- slightly elevated TSH >5.0, t4 t3 normal DO NOT TREAT, RECHECK 6 MONTHS • Hyperthyroid- TSH is low <.5 t4, t3 is high KNOW S/S • Subclinical hyperthyroid- TSH is low <.5 t4, t3, normal • Increase Synthroid - medication slowly due to cardiac affects in elderly • Pancreatitis- Alcohol abuse, family history of pancreatitis, A high level of fat (triglycerides) in the blood, Gallstones, having cystic fibrosis, Smoking cigarettes. • diabetics – risk for cataracts or glaucoma, present with microaneurysms, wool spots • Addison’s disease- hypercortisolism, darkening of skin, crave salty foods, weight loss, decreased libido, hypoglycemia TX steroid cortisol • Cushing’s disease- elevated cortisol, fatty hump, round face, pink purple stretch marks, weight gain hair loss • Chvostek sign- nerve excitability (tetany) due to hypocalcemia • Somogyi effect- too much insulin in the blood at night causes a rebound increasing blood sugar in the AM • Dawn phenomenon- early morning increase in blood sugar between 2-8am TESTS/TERMS • Valgus- test MCL • Varus-test LCL • MRI- best for soft tissues such as tendons and cartilage • X-rays- best for bone injuries, fractures • Drawer sign test- for knee stability- positive anterior drawer sign test for ACL, the positive drawers sign test for PCL • Homans sign- lower leg pain on dorsiflexion of foot, assess for DVT • Breast Ultrasound- differentiates fluid filled cyst from a solid mass • Mammography- dx breast cancer, US, MRI, fine needle core biopsy • Fructosamine test- is a tool for measuring how well your diabetes treatment program is working that is somewhere between home blood glucose monitoring and Hemoglobin A1c. Since it measures glycated protein and determines the average glucose over the past 2-3 weeks, 2-4 weeks • Cullen’s sign- edema and bruising of the subcutaneous tissue around the umbilicus • Grey-turners sign- bruising/bluish discoloration of the flank area that may indicate retroperitoneal hemorrhage • PSOAS- supine patient, patient uses resistance against examiners hand on straighten leg, side lying variation as well, test for pancreatitis/appendicitis • Obturator sign- side lying patient, inward rotation of hip, test for pancreatitis/appendicitis • Epley’s maneuver- used to TX Benign paroxysmal positional vertigo, sit, lay supine, turn head, turn again, sit up • Tandem gait- heel to toe • Romberg test- stand in front of examiner feet touching, ask patient to extend arms forward palms facing up, if patient sways and has to move feet it’s a positive test • GET UP AND GO TEST IN ELDERY • Elisa test- screening for Lyme disease and HIV, confirmed by Western blot test • Finklestein test- to diagnose de quervains tenosynovitis in wrist pain, thumb side, • Dix-Hall pike test- tests benign positional vertigo (sitting twist head) • Tinel test- tapping wrist for carpal tunnel • Phalen’s test- upside down praying hands for carpal tunnel • Murphy sign - gall bladder test (hook during inspiration) • McBurney’s point- umbilicus to great trochanter, appendicitis test, knife hand technique, press and assess pain on rebound effect • Roving’s sign- deep palpation over the LLQ with sudden unexpected release of pressure, this causes tenderness on the RLQ which a positive sign for appendicitis is • McMurray test- knee pain and click, injury to medial meniscus, (Knee feels like locking up) Dx gold standard test for joint damage is the MRI (supine raise knee twisting knee inward/outward while extending in/out) • Lachman sign- knee joint is laxity is positive, suggest ACL damage, more sensitive than anterior drawer test instability of knee • Apprehension test- tests shoulder when anterior instability is suspected, patient lays supine examiner will flex elbow to 90 degrees • Mulder test- test for Morton’s neuroma, squeeze forefoot, positive test is hearing click and pain from patient • Kernig test- leg raise while supine/meningitis • Brudinski test- head lift while supine/Meningitis • RLS- check iron level • Dyspareunia- painful sex • Virchow nodes- lymph nodes left supraclavicular are above left clavicle, sign of cancer in abdomen, gastric cancer • Koilonychia- spoon shaped nails related to IDA • Hyphae- branching filaments make up mycelium of a fungus (tomato mold) • Mini-Cog- screening tool for dementia score 2 is dementia • Globus- foreign body in throat, lump in throat generally from GERD • Von Willebrand’s disease – bleeding disorder includes easy bruising or prolonged bleeding but normal platelet count • Klinefelter syndrome- males born with extra x chromosome, gynecomastia, primary hypogonadism (deficiency in testosterone) small testicle, small penis, tall stature, wider hips,long arms, lack of second sex characterisitcs, reduced facial hair, higher risk of osteoporosis, TX testosterone replacement, fertility treatment • Turner syndrome- females with complete or partial absence of second sex chromosome, congenital lymph edema on hands and feet, webbed neck, high arched palate, short fourth metacarpal, short stature, ovarian failure, cardiovascular, renal issues, ear malformation, infertility • HELLP syndrome- complication from eclampsia, third trimester presents with symptoms of severe preeclampsia, DX AST, ALT, bilirubin, decreased PLT H&H • Zollinger-Ellison syndrome- tumors causes stomach to produce to much acid resulting in PUD • Meniere’s disease- inner ear disorder, episodes of vertigo, avoid caffeine, chocalte, tobacco, low sodium, TX meclizine (antivert), diuretics, diazepam • Korsakoff-Wernicke -dementia caused by thiamine vitamin B • Iron supplementation- avoid antacid, tetracyclines and dairy, absorbed better on empty stomach but not tolerable (grapefruit juice aids in absorption) • Empiric- a person who, in medicine or other branches of science, relies solely on observation and experiment. • Intractable- hard to control or deal with • Insidious- proceeding in a gradual subtle way but with harmful effects • Euthyroid- normal functioning thyroid • Subclinical- disease considered asymptomatic but still carrier for disease or infection • Paroxysmal- sudden or recurrent or intensification of symptoms such as seizures or spasms • Radiculopathy- pinched nerve resulting in pain, weakness, numbness, difficulty controlling specific muscles • Pyrosis- heartburn • Xanthelasma- slightly raised circumscribed plaque in eyelids due to lipid disorder • Liver - is 15-18 cm midclavicular • Threshold- the point when a stimulus is of sufficient intensity to produce an effect, KNOW ABOUT SEIZURE THRESHOLDS • Lidocaine/epi- contradicted areas are Fingers, nose, penis, toes, ok on scalp IMMUNIZTIONS • Hep B- 3 dose, given at birth • Flu -given at 6 months • Tetanus- every 10 years • Pneumococcal- pcv13 for children ppsc23 >65 years old • Shingles – at 60 years old 1-time dose • Varicella- 2 doses 4 weeks apart starting at 12 months • HIV patients- are to receive a tuberculin skin test (Mantoux test with tuberculin units 5 {TU} of purified protein derivative {PPD}-tuberculin). Those persons who have at least a 5 mm reaction to PPD should be considered for 1 year of isoniazid preventive therapy, unless otherwise contraindicated. • Mantoux >10mm positive for immigrants >5mm positive for nursing home resident • Rubella titer- give at post partum • Serious sequalae does not involve rhinovirus HEMATOLOGY • MCV-size, MCH-hemoglobin content, MCHC- measure of avg color, RDW-indicates variation of RBC size, serum iron- iron in blood, serum ferritin- iron storage, reticulocyte count- ability of bone marrow production TIBC- total iron binding capacity, if iron is low TIBC is high vice versa Red cell casts – indicate glomerulonephritis not UTI, acute/chronic renal fx nor urolithiasis • RBC- lifespan is 3 months • Bands- shift to the left means severe bacterial infection • Eosinophilia- can indicate allergies, cancer, parasitic disease • Neutrophils/Segs- biggest WBC then Lymphocytes • Bilirubin- is the breakdown of rbc, KNOW ABOUT BILIRUBIN IN BABIES • Hyper bilirubin- TX phototherapy, hydration, breast feeding or formulary feeding • Hep A- transmitted thru contaminated water and food • Hep B- transmitted thru blood, (most common is sexual activity) and mother child transfer at birth TX PEG-IFN, ETV, TDF • Hep C- transmitted thru mother and child at birth, tattoos and contaminated needles, hemodialysis, sexual contact with someone with Hep C, common cause liver cancer, Dx HCV antibody TX antivirals and PEG-IFN, • Idiopathic thrombocytopenia purpura- <30,000 plt, Plt broken down by spleen causing thrombocytopenia, Signs of bruising, petechia, purpura, epistaxis, gingival bleed, TX initial glucocorticosteroids (prednisone) • Thrombocytopenia- plt count <150,000 Signs of bruising, petechia, purpura, epistaxis, gingival bleed • CBC-is screening test for all anemias • TORCH- toxoplasma, Other infections, Rubella, Cytomegalovirus, Herpes Macrocytic anemia • b12 deficiency, - expected findings are positive Romberg/Babinski, Glossitis- burning of tongue, tingling and numbness of feet, diarrhea, dizzy, fatigue muscle weakness loss of appetite, SOB, confusion, paranoia, neuro changes causing nerve pain, TX cobalamin IM • Pernicious anemia- autoimmune disorder destruction of parietal cells which causes cessation of intrinsic factor, decreased reflexes Dx check vitamin b levels, antibody test for intrinsic factor, • Folate deficiency- alcoholic, normal signs of anemia, Dx cbc, peripheral smear, folate level give PO folate, leafy green vegetables, beans (liver, pasta cereals) Microcytic anemia • Thalassemia- microcytic, hypochromic but normal RDW, Dx electrophoresis Alpha- Philippine….Beta- Mediterranean descent, initial test is CBC Iron levels, • Iron deficiency anemia- microcytic, hypochromic, pallor, fatigue, glossitis, cheilitis, poikilocytosis/shapes, anisocytosis/size, elevated RDW, numbness and tingling in both hands, pica, koilonychia DX serum ferritn TX correct anemia, rule out GI malignancy, increase fiber fluids, iron supplementation FERROUS SULFATE BEST IRON TO ABSORB • Anemia of chronic disease- normocytic anemia normochromic, but <20% microcytic DX serum ferritn • Sideroblastic anemia-acquired or inherited, bone marrow unable to incorporate iron into hemoglobin DX Prussian blue stain of bone marrow aspirate • Aplastic anemia- destruction of stem cells in bone marrow, causes pancytopenia Dx gold standard bone marrow biopsy, CBC plt count, refer to hematologist, ER • Sickle cell,- 1/500 Africans has sickle, higher risk of death from infection, ischemic necrosis of bones, skin renal liver, frequent infections DX screen is CBC, gold test is electrophoresis, TX refer to hematologist, genetic counseling • Hodgkin’s lymphoma- cancer of b cells pruritic, painless lymph nodes, night sweats, fever, pain with alcohol drinks, young adults • Nonhodgkins lymphoma-cancer of b cells and killer cells, painless lymph nodes, older adult >65, poor prognosis • Multiple myeloma- cancer of plasma cells, fatigue, weakness, bone pain on chest to back, proteinuria (Bence jones protein) hypercalcemia • HBsAg- tells us acute or chronic infection hepatitis B surface antigen (neg for current Hep B) • Anti-HBc When this is positive or reactive, it means that. you have HBV infection or had it at some time in the past. - hepatitis B core antibody (no antibody, never had Hep B) • Anti-HBs –tells us if immune due to previous infection or vaccination hepatitis B surface antibody (positive means immunized) (positive=infected/negative= not infected) • Anti-HAV IgG- tells us if antibodies are present positive=immunized/negative= not immunized IF PATIENT IS POSITIVE ORDER HCV RNA OR HCV PCR TO RULE OUT CHRONIC INFECTION • IgE mediated reaction- previous anaphylaxis reaction NEUROLOGY • Post-concussion headache-direct blow to the head or body with an impulsive force transmitted to the head, self-reported loss of consciousness lasting <30 minutes, confusion, delayed response, change in sleep, visual disturbances, amnesia • Subarachnoid hemorrhage- The primary symptom of aneurysmal SAH is a sudden, severe headache classically described as the "worst headache of my life, brief loss of consciousness, nausea or vomiting, and meningismus, Meningismus and often lower back pain may not develop until several hours after the bleed since it is caused by the breakdown of blood products within the CSF, which lead to an aseptic meningitis. While many patients have an altered level of consciousness, coma is unusual. Seizures occur during the first 24 hours in less than 10 percent of patients but are a predictor of poor outcome. SAH may also present as sudden death; at least 10 to 15 percent of patients die before reaching the hospital. • Subdural hemorrhage- presents with symptoms of elevated intracranial pressure including headache, vomiting, anisocoria, dysphagia, cranial nerve palsies, nuchal rigidity, and ataxia. The insidious onset of headaches, light-headedness, cognitive impairment, apathy, somnolence, and occasionally seizures, may occur as a consequence of chronic SDH, patient on anticoagulants, bleeding between the e dura and subarachnoid of the brain. • Mini-mental exam/cranial nerves- neuro exam • Stereognosis- place familiar object in hand • Graphesthesia- write a large letter in hand • Cerebellum- control for balance • Bacterial meningitis- reportable infection, nuchal rigidity, decrease LOC, headache, Dx CSF lumbar puncture, CT/MRI, CBC, gram stain • Migraines – last 2-3 days, with or without aura, moderate to severe intensity with pulsating quality, aggravated by physical routine and accompanied by N/V and photophobia, phonophobia, triggered by food (alcohol, chocolate, cheese nuts, caffeine) TX rest, ice pack, avoid triggers ABORTIVE TX Imitrex rule out CVD Prophylactic TX BB or TCA’s • Cluster headaches- occurs at time/night last 15 to 180 minutes, severe ice pick lacerating pain, unilateral behind the eye or temporal pain accompanied by same side of the face sweating, lacrimation, nasal congestion, ptosis, rhinorrhea, eyelid edema, produce red teary eye, common middle aged-man TX O2, Imitrex, CCB for prophylaxis, resolve spontaneously • Tension headaches- last several days mild to moderate bilateral no pulsating pain, tightening pain that is not aggravated by physical activity, with no N/V or photosensitivity, spasms of trapezius muscle TX Nsaids, stress reduction • Essential tremor- inherited tremor treat with propranolol or atenolol • Carotid bruits- systolic sound, is a result of atherosclerotic disease of the carotid artery • Temporal arteritis- The cause of the blood vessel inflammation is unknown. In some cases, the swelling affects just part of an artery with sections of normal vessel in between. Symptoms include acute onset of headaches located on one temple, skin over artery is indurated, jaw pain, vision loss, fever, and weight loss, anorexia, fatigue. Dx usually requires biopsy of the temporal artery. Elevated sed rate and c reactive protein, high risk with polymyalgia rheumatica, the condition needs prompt treatment with steroid medications to prevent permanent vision loss. TX prednisone, methyl prednisone, aspirin nsaids, refer to ophthalmology and rheumatologist • Polymyalgia rheumatica- bilateral join stiffness located in neck hips torso, difficulty dressing TX steroids • Trigeminal neuralgia- piercing knife-like pain to one side of face, aggravated with eating and talking, TX first line is Trileptal, anticonvulsants, tegretol or Dilantin, muscle relaxants (baclofen, felexeril) MRI or Ct to rule out tumor or MS • Bell’s palsy- abrupt unilateral face paralysis, CN 8, dry eye in affected side due to no blink, TX rule out stroke, hi dose steroids x 10 days, antiviral, protect cornea • TIA- caused by ischemia to brain, symptoms eventually resolve but remains high risk for stroke, TX refer to ED, schedule CT/MRI, rule out hemorrhage before starting aspirin • CVA- caused by emboli, thrombus or hemorrhage, permanent neuro damage, risk factor afib and HTN, TX call 911, assess ABC, check vitals next, Ct scan, MRI, to see if candidate is candidate for TPA, Labs Pt, PTT, INR, CBC, Glucose, lipid, EKG, • FAST- for recognizing stroke, facial, arm weakness, speech, time • Apraxia-difficulty performing purposeful movements • Boca’s aphasia-comprehends speech but unable to verbalize speech • Wernicke’s aphasia- difficulty with comprehension but none with speech • Para thesis- numbness tingling • Cranial Nerves I Olfactory- smell II Optic- Visual acuity, vision, distance vision III Oculomotor- constriction, accommodation, movement of eyeball 6 cardinal gazes, opening eye lids IV Trochlear – movement of eye 6 cardinal gazes V Trigeminal – facial sensation, mastication, masseter strength, temporalis muscles VI Abducens- lateral movement of eye, 6 cardinal gazes VII Facial- puffing out cheeks, smile, frown, VIII Acoustic- whisper test, weber/Rinne test, Romberg IX Glossopharyngeal – taste, gag reflex, swallowing, X Vagus- speech, gag reflex, swallowing XI Accessory- shrugging shoulders, side to side movement XII Hypoglossal- tongue movement/strength, light tight dynamite STD’S • Syphilis- painless chancre heals in 6-9 weeks, clean base well demarcated in indurated margins, white papules look like warts (condyloma Lata), maculopapular rash on palms and soles not pruritic, neurosyphilis gumma (soft tissue tumors) aneurysms, valvular damaged Dx RPR or VDRL screening tests if positive, confirm with FAT-ABS test TX benthazine-penicillin IM 1 dose, for late treatment- benthazine-penicillin once per week x 3 weeks, or doxycycline • Gonorrhea urethritis, green colored, pelvic pain, vaginal discharge, penile discharge, dysuria, purulent mildly odorous, urethritis, cervicitis, proctitis, pharyngitis, endometritis, salpingitis, epididymitis, Dx NAAT testing, TX ceftriaxone IM and Azithro, annual screenings, co treat with syphilis • Sexual assault TX ceftriaxone, azithro • Chancroid- TX ceftriaxone, azithro • Epididymitis- TX ceftriaxone, doxy, flagyl • Cervicitis- TX ceftriaxone, azithro, doxy • Chlamydia- atypical bacterium, treponema pallidum, internal infection not on labia, Fitz-Hugh syndrome, asymptomatic, mucopurulent, vaginal discharge, bleeding, Dx- gold standard, nucleic acid amplification test NAAT, gen probe, antigen detection (swab), urinalysis, wet prep >20 WBC, TX Azithro 1 dose or doxycycline for 7 days annual screenings • Fitz Hugh-Curtis syndrome- chlamydial/gonorrhea infection of liver capsule extensive scarring scars look like violin strings complication of PID • Nongonococcal Urethritis- TX azithro, doxy • Pharyngitis- TX ceftriaxone, azithro, doxy Dx Thayer- Martin • Proctitis- TX ceftriaxone, azithro, doxy Dx Thayer-Martin • Orchitis- same as mumps virus • Prostatitis- TX ceftriaxone, doxycycline flagyl • PID- risk factors history of PID, age 25 or younger, adnexal tenderness, cervical motion, uterine tenderness, lastly temp >101.f, DX NAAT TX ceftriaxone, doxy, flagyl • Trichomoniasis- yellow-greenish discharge with dyspareunia, pelvic exam reveals strawberry patches on cervix, dx is wet mount/prep, flagella, partner needs treated too TX flagyl PO for 7 days • BV- asymptomatic, grayish white milky, watery discharge, unpleasant fish odor, Dx wet mount clue cells (mature squamous epithelial cells with numerous bacteria on cell borders, surfaces edges are coated with bacteria), gram stain, TX flagyl PO for 7 days • Herpes-HSV1 is oral, HSV2 is genital, DX herpes viral culture or RPR assay (more sensitive) TX acyclovir 7- 10 days, famciclovir 5 days • Tzanck smear- used as adjunct for evaluation herpetic infections, positive smear will show large abnormal nuclei squamous epithelial cells, (Giant cells)not commonly used • Human papilloma virus- HPV strain 16/18 are carcinogenic, soft painless flesh colored warts, TX podophyllum resin, trichloroacetic acid- causes acetowhite changes, cryotherapy, Imiquimod, laser CONTRAINDICATED IN PREGNANT WOMEN OR MECHANICAL METHODS • Scabies lice- TX permethrin • Candidiasis- thick white curdy discharge Dx wet mount, TX clotrimazole, miconazole • Yeast- TX clotrimazole, nystatin, miconazole • Low grad Intraepithelial lesions cervical cells that appear slightly abnormal but not precancerous • High grade squamous intraepithelial lesions- precancerous cells not cancer HPV testing and refer to colposcopy • AIDS- identified CD4 t lymphocyte count <200, oral candidiasis, fever wt. loss diarrhea, SOB, purple to bluish red bumps on skin (Kaposi sarcoma). Pneumocystis jirovecii TX Bactrim is infection that causes most deaths with HIV DX HIV1/HIV2 antibodies test and P24 antigen, step 2 HIV1/HIV2 antibodies differentiation immunoassay if indeterminate HIV RNA Prophylaxis is Bactrim TX Antiretroviral therapy ART, HIV women take AZT (zidovudine) Goal- prevent therapy for PCP, pneumocytis pneumonia jiurevisitis • Acute HIV- flu like or mono like infection, symptoms in persons infected within 2-4 weeks, HIV antibodies detected 3 months after exposure DX HIV RNA, PCR test • NAAT- can detect HIV infection in 7-28 days • Elisa/Western blot- detects HIV antibodies • Disseminated Gonococcal disease- petechial or pustular lesions on hands sole, swollen, red, tender joints, asymmetrical joints, signs of STD Urethritis, cervicitis, pharyngitis with green purulent sputum • UTI- TX Bactrim or Macrobid, spermicide increase risk • Enterobiasis (pinworms)- scotch tape, early morning • Lichen sclerosus- (balanitis xerotica) whitish patches on genitals, lesions chronic affect vulva/anal in elderly patients, risk for cancer PULMONOLGY • Pneumonia-community acquired pneumonia, Dx cxray, cbc showing shift to the left bands Strep pneumo- rust colored sputum, abrupt onset, TX no Abx exposure macrolide or tetracycline…. with abx exposure fluoroquinolone, doxycycline, or macrolide with Augmentin Atypical pathogens- outside lung issues (joint aches, arrhythmias), TX no abx exposure Macrolides, tetracyclines or fluoroquinolones……with abx exposure fluoroquinolone or macrolide with Augmentin • COPD- loss of elastic recoil of the lungs, and alveolar damage. diagnostic features include symptoms (sob, cough, sputum), Exposure to risk factors (tobacco, occupation, indoor/outdoor pollution), Spirometry (required to establish diagnosis fev/fvc ratio <.70, BUT not during an exacerbation Treatment SAA or SABA---LABA or LAAC and SAA or SABA ICS and LABA or LAAC and SAA or SABA • Anticholinergic- can’t think or blink, can’t see (Increase eye pressure) or pee, can’t spit or shit, SADCCUB sedation, anorexia, dry mouth confusion, constipation, urinary retention, BPH • Fexofenadine- Allegra, (allergy medication) • Eosinophilia - is common with atopic dermatitis, allergic response, asthma • Bronchiolitis- Bronchiolitis is almost always caused by a virus, no abx, treat with antipyretic • Vesicular breath sounds- heard in the base of the lungs • Pertussis- whooping cough, healthy adult with no fever, coughing for 2-3 weeks TX with macrolide dx nasal swab pcr, Elisa, cbc • PFT-during expiration, based on height age and gender (HAG), gold standard for diagnosing COPD, emphysema, chronic bronchitis, • Spirometry- green zone maintain or reduce meds, yellow zone maintenance therapy needs increased, Red zone give epinephrine, call 911 • Acute bronchitis- viral, TX symptomatic, new onset cough, dry, low grade fever, normal cxray, mild wheezing, chest pain • Chronic bronchitis- production of sputum for at least 3 months annually for 2 consecutive years accompanied by cough, stage 1-SABA (albuterol) or SAAC(ipratropium) and/or low dose theophylline, <2 per month night awaking’s stage 2- SABA or SAAC, and LABA(salmeterol), rehabilitation, nightly awakenings 3-4 per month stage 3- SABA or SAAC, LABA, inhaled glucocorticoids(fluticasone), rehabilitation nighttime 1 per week stage 4- SABA or SAAC, LABA, inhaled glucocorticoids, rehabilitation, long term oxygen, surgical treatments • Asthma- nonproductive cough, expiratory wheezing, sob, tachypnea/cardia, nocturnal dyspnea, Dx dyspnea, cough, wheeze, variable expiratory airflow, TX Intermittent - SABA Mild persistent – low ICS and SABA Moderate persistent – med ICS and LABA and SABA Severe persistent- high ICS, LABA, SABA • Inhaled corticosteroids- long term effects cataracts, glaucoma and osteopenia, schedule eye exam and bone density, supplement with calcium+ vitamin d • Croup- acute viral illness characterized by stridor, barking cough, and hoarseness, nasal flaring, drooling, abdominal breathing, use of accessory muscles, “thumb sign used to describe swelling of epiglottis seen on lateral radiograph of neck” • CURB- 65- confusion person place or time, Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) respiratory rate > 30 breaths/minute Blood pressure (systolic <90 mmHg or diastolic <60 mmHg) Age ≥65 years 0-1 home treatment, 2 short in-patient hospitalization, >3 severe pneumonia, hospitalize, consider ICU • Respiratory- increases with hypercapnia, retention of Co2 • Hay fever/allergic rhinitis- use nasal steroid gold standard • Sputum culture- Dx gold standard for TB diagnosis, collection for 3 days, NAAT test • FEV1 and FVC- decrease with age but residual volume increase GASTRO • RUQ pain- liver gallbladder, ascending colon, pancreas, right kidney • LUQ pain- stomach, pancreas, descending colon, kidney • RLQ pain- appendix, ileum, cecum, ovary • LLQ- sigmoid colon, ovary, diverticulitis • Suprapubic pain- bladder, uterus, rectum • Pancreatitis- midepigastric pain radiates to midback • Acute appendicitis- has positive PSOAS and obturator signs, Dx pancreatic enzymes, liver enzymes and leukocytosis, US and/or CT TX refer to ED • Gerd-symptoms worsen with fatty meals or when supine, decreased lower esophageal sphincter tone, risk factors- alcohol, anticholinergic, CCB, chocolate peppermint, fatty, spicy, citrus foods, hormones, obesity, pregnancy, smoking, theophylline, exacerbated by CCB verapamil TX first line is lifestyle changes then H2 blockers first then PPI • PPI’s - cure ulcers faster than H2 • Barret’s esophagus- metaplastic columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus [1,2]. The metaplastic epithelium is acquired as a consequence of chronic gastroesophageal reflux disease and predisposes to cancer development. Dx upper endoscopy with biopsy, Refer to oncology! TX PPI omeprazole, • Diverticulitis- small pouch like herniations, acute onset of fever, LLQ pain, anorexia, N/V, Dx CBC, leukocytosis, shift bands to left, TX fluoroquinolone, flagyl, , if severe refer to ER • Pencil like stool-DESCENDING COLON CANCER caused by constipation, colorectal cancer, fecal impaction, polyps, abdominal hernias, anorectal strictures, distended or stretched colon and twisted bowel or volvulus, crohns, ulcerative colitis, IBS, Refer to GI for colonoscopy • Pyloric stenosis- narrowing of pyloric sphincter causing eventual obstruction, characterized by forceful vomiting in young infants, projectile post prandial nonbilious vomiting, olive shaped mass palpable RUQ, hunger and weight loss and dehydration, 2 weeks of age dx US, TX surgical • IBS- TX fiber, avoid gas foods, antispasmodics, decrease life stress • KNOW S/S FOR INFLAMATORY BOWEL • PUD-helicobacter pylori, pain relieved by foods and or antacids, Dx gold standard upper endoscopy and biopsy gastric/duodenal tissues, detect h pylori infection, CBC, if positive, refer to gastro, urea breath test, stop NSAIDS, smoking, TX PPI or H2 blockers is initial TX of H. Pylori, ranitidine, famotidine, cimetidine, H. pylori- positive ulcers require 14-day treatment (amoxicillin, azithromycin, doxycycline) Triple therapy is clarithomycin, amoxicillin, and omeprazole GENITOURINARY Urinalysis results KNOW WHAT CONTAMINATED SPECIMEN WOULD SHOW. KNOW ABOUT NEPHROTIC SYNDROME SPECIFIC GRAVITY Increased=dehydration, CHF, DM……Decreased= diabetes insipidus pyelonephritis excess fluid pH ACIDIC=diet, copd, ketoacidosis, ALKALINE= diet sodium bicarb, vomit, UTI, met alkalosis BILIRUBIN= positive means jaundice EPITHELIA CELLS- few are normal, large amounts means contamination BLOOD= positive for kidney stones, tumors, trauma, infection, coagulation problems, few RBC <5cells normal in urine, kidney stones pyelonephritis cystic, glomernephritis GLUCOSE= positive diabetes mellitus, pancreatitis, Cushing syndrome, shock, burns, steroids, renal disease, hyperthyroidism, cancer KETONES= positive means starvation, ketoacidosis, vomit, diarrhea, pregnancy NITRATES= positive means infection with E.coli PROTEIN= positive means kidney disease, pregnancy, CHF, diabetes, cancer LEUKOCYTES= positive means infection, WBC casts UTI or pyelonephritis • Serum creatinine- better measure of function than Bun/creatinine ratio • Urine C&S- to detect UTI • Pyuria- pus in urine • Dysuria- pain or burn during urination • Hematuria- few RBC <5cells normal in urine, kidney stones pyelonephritis cystic • UTI- (acute cystitis) caused by E coli, >10’5 or 1000,000 CFU/ml means UTI, dysuria frequency, no fever, nocturia • Uncomplicated UTI- oral abx for 3 days, 1. TX Sulfa (Bactrim x 3 days), if allergy to sulfa Macrobid fluoroquinolones, penicillin, cephalosporin • Complicated UTI- oral abx for 7-14 dyas1. TX fluoroquinolones, Bactrim, allergy to sulfa cephalosporin • Acute Pyelonephritis- high fever wbc casts, chills dysuria frequency, unilateral pain TX ceftriaxone IM or fluoroquinolone if resistance, 2nd line TX Augmentin and Bactrim • Acute renal failure - abrupt onset oliguria, edema wt. gain, lethargy, Nausea elevated creatinine, GFR is off • Urothialiasis- kidney stone, severe colicky flank pain comes in waves, patient cannot stay still and may stand or walk, N/V, Dx strain Urine, 1st is Renal US, highest sensitivity/specificity is noncontrast CT, UA, refer to urology refer to ER if high fever AVOID high oxalate foods, rhubarb, spinach beets, chocolate tea and meats • Bladder cancer- hematuria, dysuria, frequency, low abdominal pain, pelvic pain, perineal pain, lower back pain or bone pain Dx UA, urine culture, urine for cytology MUSCOLOSKELETAL • Navicular fracture- wrist pain palpation Hx of falling, 2nd x-ray will show fx, hi risk necrosis and nonunion, TX splint wrist refer to hand surgeon • Thumb Spica cast- cast for wrist fractures (scaphoid bone in wrist), DO YOU SPLINT AND WAIT OR DO YOU REFER, READ QUESTION WELL • Colles fracture- fracture of distal radius of the forearm, DINNER FORK fracture, most common type wrist fracture • Pelvic fracture- high energy trauma, ecchymosis and swelling, lower abdomen, hips, groin, scrotum, may have bladder or bowel incontinence, hematuria, may cause internal hemorrhage life threatening TX check ABC’s • Hip fracture- sudden onset of one side pain, elderly have one-year mortality rate, • Lateral epicondylitis- tennis/golfers elbow, pharm TX =nsaids, anti-inflammatory cream, intraarticular corticosteroid injection, nonpharm TX= rest, ice, brace, physical therapy, referral- ortho, PT/OT • Ottawa rule (ankle)- used to determine when a patient needs radiographs of injured ankle in ED, 1,2,3, Grades, 2 needs x-ray, 3 referrals to ER for ankle fracture • Medial tibial stress syndrome/fracture- injury of overuse of the muscles tendons and bone tissue of the tibia, shin splints, pain of overuse of the large front bone in lower leg, Dx bone scan or MRI, TX RICE, stretching, massage, nsaids, • Plantar fasciitis- acute or recurrent pain, bottom of foot, aggravated by walking, caused by micro tears in the plantar fascia due to tightness of the Achilles tendon, elevated risk factors BMI>30, diabetes, aerobic exercise, pes planus (flat feet), prolonged standing TX Nasid, orthotic foot appliance, ice pack, stretching with golf ball sole of feet, x-ray to rule out fracture • Pes planus (flat feet)- TX brace, stretching arch support • Gout exacerbations- crystal deposits in joints, elevated uric acid, caused by excess dietary purines (beef, pork, lamb, seafood, beer, bread, gravy, alcohol) Dx gold standard is joint aspiration of synovial fluid Labs- uric acid level, CBC, ESR TX NSAIDs Indocin), colchicine for flare up, corticosteroids Podagra means gout of the foot • Osgood-Schlatter- occurs during growth spurt and affects superior tibia, when quadriceps exert stress on the patellar tendon (tibial tubercle), anterior knee pain increases over time • Tubercle -small round projection on bone or surface • Bouchards node- typical in osteoarthritis, enlargement of proximal interphalangeal joint • Ankylosing spondylitis- (Bechterews disease) inflammatory arthritis affecting spine and large joints, pain improves with exercise not rest, low grade fever, fatigue, marked loss of ROM, humpback, uveitis, Dx labs sed rate, C reactive protein, spinal radiograph bamboo spine, TX refer to rheumatologist, first line is NSAIDS, postural training • Cauda equina syndrome- medical emergency, spinal cord compression, B/B dysfunction, TX refer to ED, needs decompression • Morton’s neuroma- painful condition hurts the ball of your foot, between third and fourth toe, involves thickening of tissue around nerves leading to your toe, toe may sting, burn or feel numb, DX with clinical presentation and history, small nodule between third and fourth toe, linked to tight fitting shoes and high heels, TX with corticosteroid or surgery, avoid tight shoes, • Arthritis TX- Tylenol first line, nsaids- Celebrex, topical nsaids • Degenerative joint disease/OSTEOARTHRITIS- cartilage covering surface of joints becomes damage from overuse, obesity, affects distal interphalangeal joints, early morning stiffness<15 minutes, swollen tender joints, ASYMMETRIC symptoms, Bouchards nodes (Proximal) and Heberden’s nodes (Distal) DX physical exam or radiographs, TX first line treatment is Tylenol, nsaids, steroidal injections only, no oral steroids, glucosamine sulfate supplement • Rheumatoid arthritis- autoimmune disorder inflammation of multiple joints plan is to prevent the joint damage, presents with bilateral pain and swelling of proximal interphalangeal joinst, SYMMETRICAL DISTRUBUTION, signs of fatigue, low grade fever, body aches, myalgia, GENERALIZED joint pain, early morning stiffness >1 hour, weight loss, anorexia, neurophathic pain in the extremities or eyes, chest pain upon inspiration, warm and tender swollen fingers “sausage joints” Dx intital test is sed rate, Creactive protein, CBC, rheumatoid factor, TX refer to rheumatologist, surgery, NSAIDS, steroids, Humira Anti TNF biologics, antimalarial- Plaquenil, can cause uveitis Severe RA go swimming • Osteoporosis- deterioration of bone tissue caused by hormonal changes, calcium vitamin d deficiency, risk factors- patients on PPI, patients with anorexia/bulimia females, family history, age; estrogen and testosterone deficiency, kyphosis, Caucasians and Orientals, small frame people, cigarette, alcohol, caffeine, medication- steroids anticonvulsants, thyroid supplements, eating disorder, sedentary life, Dx bone mineral density >-2.5 osteoporosis TX first line is bisphosphonates alendronate, Fosamax, calcium500 mg, vitamin d thru food and supplementation, testosterone, wt bearing exercise • Osteopenia- increase calcium dark green vegetables, salmon, sardines, soy and OJ • slipped capital femoral epiphysis- is a medical term referring to a fracture through the growth plate (physis), which results in slippage of the overlying end of the femur (epiphysis).SCFE is also more likely to happen to teens who have specific stuff going on with their health, such as: obesity (carrying extra weight puts increased pressure on the growth plate) endocrine disorders like diabetes, thyroid disease, or growth hormone problems. kidney disease. TX in situ fixation. This is the procedure used most often for patients with stable or mild SCFE. The doctor makes a small incision near the hip, then inserts a metal screw across the growth plate to maintain the position of the femoral head and prevent any further slippage. Nonwt bearing, referral to ortho for pinning • KNOW ABOUT TRENDELENBURG TEST • Intermittent claudication- take ankle /brachial B/P before and after exercise • Metatarsus adductus- (pigeon toe) also known as metatarsus varus, is a common foot deformity noted at birth that causes the front half of the foot, or forefoot, to turn inward. TX teach parent to perform passive stretching into straighten position several times a day, serial casting every 1-2 weeks or surgery for correction • Club foot- talipes equinovarus, involve lower extremity and foot, TX brace, stretching, casting, surgery • Nursemaids elbow- injury in 1-4-year-old, TX reduction to put back in place, or device wearing splint • Polymyalgia rheumatica- inflammatory disorder causing muscle and joint pain and stiffness (shoulders/hips), aching stiffness about the upper arms, neck, lower back and thighs, symptoms develop quickly, and worse in the morning, DX elevated sed rate, Creactive protein, 1st line TX oral prednisone • Fibromyalgia/chronic fatigue syndrome- depression, dysrhythmias or anxiety disorders, malaise fatigue, multiple joint pain, headaches, impaired memory, and concentration, sore throat, restless sleep, muscular pain for 3 months, TX cognitive based therapy CBT. KNOW HOW TO DX FIBROMYALGIA. Geriatrics • Tremor- 1st line treatment is Propranolol/Inderal • Insomnia in elderly- give Ambien not Benadryl • Death- 1. Heart issues, 2. Cancers (lung, colorectal), 3. Chronic lower respiratory disease • Lung cancer -highest mortality, smoking common risk factor, non-small cell carcinoma, Dx gold standard lung biopsy, cxray, CBC, refer to pulmonologist low dose CT, stop screening if smoking stops for 15 years or short life expectancy • Colorectal cancer- risk factors age, IBD, family history, colon polyps, lifestyle risk factors, Dx screen at 50 colonoscopy, sigmoidoscopy in 5 years, fecal occult test, CBC, refer to gastro • Multiple myeloma- cancer of the bone marrow, bone pain, weakness, TX CBC, FOBT, refer to hematologist affects African race • Pancreatic cancer- lethal cancer 5-year survival rate, most metastases by time of diagnoses, weight loss , anorexia, jaundice weakness, and abdominal pain TX AST ALT bilirubin lipase amylase refer to GI surgeon for Whipple procedure • Ribbon like -or pencil like stool rule out colon cancer • Hip fracture- acute onset of limping, guarding, difficulty bearing weight, new onset of hip pain referred to knee or groin, unequal leg length, affected led is abducted • Cataracts- opacity in lens, difficulty with glare, halos around light, blurred vision, gradual onset of decreased night vision, red reflex disappears (Red reflex is now opaque gray instead of orange red glow) COMMON CAUSE OF BLINDNESS DEVELOPING COUNTRIES • Macular degeneration- loss of center vision, loss of visual acuity, contrast sensitivity but still have peripheral vision, may find Drusen bodies, Dx Amsler grid to evaluate central vision changes COMMON CAUSE OF BLINDNESS IN UNITED STATES • Retinal detachment- sudden onset of shower floaters/specs with looking thru curtain with sudden flashes of light, risk factors extreme nearsightness, cataract surgery, family history, TX laser surgery or cryopexy (freezing) refer to ED, lead to blindness • Arcus senilis- an arc or circle around the cornea, common in older adults >50, opaque grayish to white ring at the periphery of the cornea, not associated with visual changes, caused by cholesterol and fat deposit, Dx check lipid profile • Cellular immunity- is affected by age than humoral immunity • Caregiver burnout- is a state of physical, emotional, and mental exhaustion that may be accompanied by a change in attitude -- from positive and caring to negative and unconcerned, Caregivers who are "burned out" may experience fatigue, stress, anxiety, and depression anxiety, depression, irritability, feeling tired and run down, Difficulty sleeping, Overreacting to minor nuisances, New or worsening health problems. • Open angle glaucoma- chronic form, before loss of peripheral visual fields, its asymptomatic, excellent prognosis if TX early • Angle closure glaucoma- ill appearing, sudden decrease visual acuity, eyes reddened, profuse tearing, acute onset of eye pain, acute visual loss, severe headache, N/V, may lead to blindness, halos around lights, cloudy cornea, TX refer to ED tonometry in ED to measure IOP • IOP intraocular pressure - caused by obstruction of the outflow channels, especially the meshwork (affected by aging), or overproduction of the aqueous humor. Ocular trauma, inflammation of the uveitis, chronic steroid use, vasoproliferative retinopathy, and recurrent retinal hemorrhages, KNOW WHAT PART OF THE EYE CAN BE SEEN ON OPTHOMOLOGIC EXAM THAT WILL SHOW IOP • Temporal arthreitis- temporal headache one side with tenderness or induration over temporal artery, sudden visual loss in one eye, scalp tenderness on affected side DX elevated sedimentation rate, CRP, refer to ER • CVA- sudden onset of neuro dysfunction worsens within hours, brain attack, blurred vision, slurred speech, one sided weakness, hemianopsia, confusion, symptoms dependent on side of infarct, TIA is temporary episode lasting less than 24 hours • Cachexia- underlying illness involving marked weight loss and muscle loss. • Sarcopenia- loss of muscle mass related to aging • Orthostatic hypotension - systolic blood pressure drops 20 mmHg or more within 3 minutes moving to a more upright position • Celecoxib- NSAID increases risk of GI bleed or ulceration • Octogenarian- a person who is from 80 to 89 years old. • Hordeolum- sty • Presbycusis- high pitch hearing loss from aging, generally sensorineural not conductive • Conductive hearing- loss involves external canal and middle ear preventing sound from traveling beyond the middle ear • 5 alpha reductase inhibitors- reduces prostate size • Urinary incontinence – not normal sign of aging, TX lifestyle modifications, dietary, Kegel absorbent pads, refer to urologist • Stress incontinence- pressure form laughing, sneezing coughing, TX Kegel exercise decongestants • Urge incontinence-sudden strong urge to void immediately, overactive bladder TX anticholinergics/oxybutynin, impamine/tricyclic/antidepressant • Overflow incontinence- frequent dribbling from full bladder, due to blockage BPH, TX BPH TX • Functional in incontinence-problems with mobility, pulling pants down TX physical therapy bedside commode • Mixed incontinence-stress and urge incontinence • Cystocele- herniation of bladder TX refer for pessary placement • Rectocele- rectum TX Kegel, avoid straining, pessary placement • Uterine prolapse-cervix, TX avoid straining, pessary placement, surgical repair by urologist • Chronic constipation- TX education and behavior modification, dietary changes, bulk forming fibers, physical activity, fluid intake, laxative treatment, bowel retraining program • Dementia- irreversible brain disorder involves loss of learned cognitive and physical/motor skills, common cause is 1. Alzheimer, 2nd vascular Dx brain image MRI, thorough history of patients changed behavior, memory, function, personality form family, cognitive testing performance scales (flostein mini-mental exam MMSE, min- cog, ACE-R, Beck depression, ADL self-performance, Index of social engagement) TX thorough health, drug, medical history, family interview, refer to neurologist, MRI of brain preferred image testing • Alzheimer- accumulation of neurofibrillary plaques/tangles cause permeant damage to brain life expectancy 65 years old, diagnosed 4- 8 years, 3 A’s Aphasia- difficulty verbalizing, Apraxia- difficulty walking, agnosia- inability to recognize familiar people or objects Alzheimer TX- cholinesterase inhibitors – Aricept/donepezil, galantamine/razadyne, rivastigmine/Exelon, memantine/Namenda, ginko bilba, refer to neuro • Dementia with Lewy bodies Symptoms: People with dementia with Lewy bodies often have memory loss and thinking problems common in Alzheimer’s but are more likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and slowness, gait imbalance or other parkinsonian movement features. Vascular dementia- Previously known as multi-infarct or post-stroke dementia, vascular dementia is less common as a sole cause of dementia than Alzheimer’s, accounting for about 10 percent of dementia cases. Symptoms: Impaired judgment or ability to make decisions, plan or organize is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer's. Occurs from blood vessel blockage or damage leading to infarcts (strokes) or bleeding in the brain. The location, number and size of the brain injury determines how the individual's thinking and physical functioning are affected Alzheimer's disease Most common type of dementia; accounts for an estimated 60 to 80 percent of cases. Symptoms: Difficulty remembering recent conversations, names or events is often an early clinical symptom; apathy and depression are also often early symptoms. Later symptoms include impaired communication, poor judgment, disorientation, confusion, behavior changes and difficulty speaking, swallowing and walking. Frontotemporal dementia- Includes dementias such as behavioral variant FTD (bvFTD), primary progressive aphasia, Pick's disease, corticobasal degeneration and progressive supranuclear palsy. Symptoms: Typical symptoms include changes in personality and behavior and difficulty with language. Nerve cells in the front and side regions of the brain are especially affected. • Delirium- acute confusional state, reversible temporary process, duration hours to days, acute and dramatic onset, excitable irritable combative short attention span, memory loss disorientation, fever, shock, dehydration, substance abuse, drug to drug interaction, infection, electrolyte imbalance, TX treat illness, infection and delirium will resolve • Sun downing phenomenon- occurs in both delirium and dementia patient becomes agitated, confused, combative, resolves in morning TX avoid quiet and dark rooms, well- lit rooms avoid drugs that affect cognition • Parkinson’s disease- progressive neurogenerative disease depression is common, 3 symptoms tremor, muscular rigidity, bradykinesia, gradual onset of pill rolling, shuffling gait, poor balance, mood disorders, daytime sleepiness, worsening sebhorric dermatitis, TX bradykinesia tremors, Carbidopa/levodopa, physical therapy speech therapy, deep brain stimulation, refer to neuro • Essential tremor -action or postural tremor not resting tremor, not curable but can be controlled with medication TX propranolol, Mysoline refer to neurologist • Anosmia- loss sense of smell • Anomia- form of aphasia, unable to recall names of everyday objects • Aphasia- difficulty verbalizing, • Apraxia- difficulty to remember learned motor skill • Ataxia- difficulty cording voluntary movement • Astereognosis- inability recognize object placed in palm • Agnosia- inability to recognize familiar people or objects • Amnesia- memory loss • Akinesia- reduced voluntary muscle • Akathisia- intense need to move, restlessness • Abulia- loss of motivation or desire to do tasks, urinates in public • Brocas aphasia-ability to speak but not comprehend • Cofabulation- lying due to not remembering event • Dyskinesia- abnormal involuntary muscle rigidity • Dystonia- involuntary repetitive muscle movements muscle spasms • Abstract thinking- when asked to interpret a proverb • Flostein mini-mental exam MMSE- popular screening for dementia and Alzheimer’s MENTAL HEALTH • Acute serotonin syndrome- high levels of serotonin, high fever, muscular rigidity, mental status changes, hyperreflexia, dilated pupils, life threatening reaction, contraindicated with MOA, TCA, SSRI • Malignant neuroleptic syndrome- rare life threatening idiopathic reaction from typical and atypical antipsychotics, affect dopamine in the brain, high fever, muscular rigidity, mental status, fluctuating BP, urinary incontinence, • • Baker act - allows 72 hours involuntary detention for evaluation and treatment of high risk suicidal patients • Atypical antipsychotics- Zyprexa, Risperdal, Seroquel • Typical antipsychotic- Haldol black box warning • Antipsychotics- sudden death in elderly, prolong QT interval fata arrhythmia torsade’s de point • Anticonvulsant- Lamictal,Tegretol, Depakote • SSRI-side effect- loss of libido Erectile dysfunction, anorexia, SSRI- first line treatment of OCD/depression, celexa/citalopram, Lexapro/escitalopram, Prozac/fluoxetine, Zoloft/sertraline, Paxil/paroxetine • Atypical antidepressant- Wellbutrin (increases risk of seizures) , Zyban(smoking) • SNRI- Effexor, Cymbalta • TCA- for depression, can be for post herpetic neuralgia, Elavil, doxepin, nortriptyline, side effect- suicide, hoard pills, cardiac arrhythmias and neuro effects seizures • Lithium- bipolar disorder • MAO- contraindicated with other antidepressants and high tyramine foods ( fermented foods, beer cheese wine fava beans) • Benzodiazepines- anxiety panic or insomnia, • Valium- used for severe alcohol withdrawal and seizures • Depression- disturbance in cognitive, emotional behavior, somatic regulations, depressed mood and loss of interest or pleasure are major symptoms, (depressed mood for 2 weeks or longer, anhedonia, decreased/increased appetite, weight loss or gain, sleep disorder, psychomotor agitation or retardation, fatigue, loss of energy, feeling of worthlessness(poor self-image), inappropriate guilt, recurrent thoughts of death(suicide), difficulty thinking or concentrating/indecisiveness Dx labs CBC, TSH, Vit B12 TX rule out other disease refer psychotherapy ,first line SSRI • Extrapyramidal symptoms – akinesia- inability to initiate movement, akathisia- unable to stay still, tardive dyskinesia- involuntary movements- lip smacking, tongue face and extremities • Anhedonia- inability to experience pleasure from activities usually found enjoyable • ADHD- is a behavior disorder, common comorbidities- oppositional defiant disorder, conduct disorder, learning disorder, depression, anxiety, tics and Tourette’s, bipolar and substance abuse • Zoloft- SSRI, antidepressant, sertraline, reduce sperm count, increases infertility Black Box warning • Zyprexa- olanzapine, antipsychotic, for schizo and bipolar, monitor CBC for low WBC, weight, b/p, mental status, lips, prolactin, glucose CAUSES ELEVATED LIPDS • Bipolar- is characterized by mania and depression refer to psychiatrist TX lithium, Depakote, SSRI • Schizophrenia- delusions, paranoia, disorganized speech, hallucinations, refer to psychiatrist, KNOW MEDS AND TX • Grandiosity- inflated sense of self, during manic episode, bipolar symptom, narcissistic disorder, special powers, spiritual connections, or religious relationships • Anorexia nervosa- onset adolescence, fear of gaining weight, purging uses laxatives, vomiting, binge eating, food restriction, complications osteoporosis, BMI <18.5, lanugo, amenorrhea, peripheral edema, cardiac arrhythmias • PTSD- characterized by flashbacks of traumatic event, DX PTSD checklist, PCL-5, TX first line treatment SSRI, cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR) • St john wort- depression, menopausal symptoms, • Kava Kava/valerian root- anxiety and insomnia • Attention and calculation- spelling or counting backwards • Alcohol abuse - is when maladaptive behavior pattern occurs from repeated alcohol abuse BAC >.08 is illegal Dx GGT, AST ALT • Cage Questionnaire- screening for problem drinking or dependence, 2 out 4 suggests alcohol abuse • Acute delirium tremors- sudden onset of confusion, delusions, hallucinations, grand mal seizures TX benzodiazepine, Vitamins AA, refer to ED • Korsakoff’s syndrome- chronic thiamine deficiency, • Smoking cessation- nicotine gum, chew and par in buccal mucosa, no smoking cause nicotine overdose, cause MI, HTM TX Zyban and/or Chantix • Insomnia- first line TX is sleep hygiene, refer to sleep lab, Benadryl, Benzodiazepines Men’s Health • Priapism- painful erection for 2-4 hours, ischemic form is medical/surgical emergency • Testicular cancer- hard fixed, nodule, heaviness or aching, one testicle larger than other, hydrocele from tumor, painless asymptomatic until Metz, Dx, Gold standard testicular biopsy, US of testes, refer to urology, for surgical removal (orchiectomy) • Prostate Cancer- most common cancer in men, new onset of low back pain, rectal perianal area, obstructive voiding symptoms, weak stream, nocturia, risk factor obese and family history, >50 years old, Dx routine screening not recommended, • Torsion of the appendix testes-, blue dot sign, blue colored round mass located on testicular surface, polyp like structure attached to testicular surface, infarction and necrosis of the appendix due to torsion, refer to ER • Testicular torsion- abrupt onset extremely painful and swollen red scrotum, N/V, affected testes higher and closer to body, the cremasteric reflex is missing, >not corrected in <6 hours permanent damage, if not corrected in 24 hours becomes gangrene, common in males with bell clapper deformity TX call 911, US doppler preferred test, manual reduction or surgery, elevated PSA, biopsy of prostate tissue, PSA level with DRE TX refer to urologist, individualize screen per risk factors • Varicocele- enlargement of the veins within the scrotum, bag of worms, testicular tumor, can cause infertility, DX US of scrotum, TX surgical removal of varicosities • Hydrocele- fluid filled sac around testicle, swelling of scrotum, asymptomatic, DX will glow with transillumination, US of scrotum, TX refer to urologist • Direct inguinal hernias- are found in the Hesselbachs triangle • Indirect inguinal hernia- are common on the right side internal ring • Cryptorchidism- a testicle that has not moved into the bag of skin below the penis before birth, maybe one or two, increases risk of testicular cancer • BPH- gradual development of urinary obstruction, weak urinary stream, postvoid dribbling, occasional urinary retention, Dx PSA is elevated, prostate enlarged, TX alpha adrenergic antagonist- terazosin/Hytrin-first for patients with HTN, Flomax, or Proscar- shrinks prostate by 50 % • Chronic bacterial prostatitis- > 6 weeks infection, gradual onset, asymptomatic or UTI, caused by E. coli, suprapubic or perineal pain, irritative voiding, dysuria, nocturia, frequency, Dx boggy prostate, urine and prostatic fluid cultures, three tubes, PSA elevated, TX Bactrim, fluoroquinolone • Acute prostatitis- infections ascends to urinary tract, E.coli, sudden onset of high fever, chills, suprapubic pain perineal discomfort, radiates to back to rectum, UTI, symptoms, Dx DRE reveals tender prostate warm and boggy, CBC shows leukocytosis, pyuria, urine culture, TX ceftriaxone tetracycline, macrolide, fluoroquinolone, refer if septic shock • Acute bacterial epididymitis- bacteria ascend the urethra, urethritis, reaching epididymis, rule out testicular torsion, E.coli, swollen red scrotum, unilateral testicular tenderness with urethral discharge, hydrocele with symptoms of UTI, fever, green colored purulent or serous clear discharge, Prehn’s sign positive with relief of scrotal elevation DX leukocytosis pyuria, hematuria, Urine culture, test for gonorrhea/chlamydia TX ceftriaxone, doxycycline, or fluoroquinolone • Erectile dysfunction- due to vascular insufficiency, neuropathy, medications, smoking, alcohol TX first line TX phosphodiesterase type 5 inhibitor, Viagra Levitra • Peyronie’s disease- inflammatory disorder of the penis with fibrotic plaques on the tunica albuginea, penile pain during erection, palpable nodules cause deformity penile erections, may resolve or require surgery, TX refer to urologist • Balanitis-candidal infection of the glans penis, diabetic or immunocompromised men, TX topical azole cream, treat partner too • Phimosis- foreskin cannot be pushed back due to edema, seen in neonates Women’s health KNOW POST MENOPAUSE BLEEDING TO YOU DO ULTRASOUND FIRST OR REFER FOR ENDOMETREAL BIOPSY • Dominant breast/breast cancer- mass one side feels hard, irregular, immobile, located tail of spence, skin color peu d orange (resembles orange peel), dimpling retraction, painless, bloody nipple discharge, DX order mammogram, refer to breast surgeon • Paget’s disease of the breast- chronic red scaly rash resembling eczema starts on nipple and spreads to areola, itching, pain, burning sensation, skin lesion enlarges includes crusting, ulceration and bleeding at the nipple • Inflammatory breast cancer- recent or acute onset red swollen warm area in breast of younger woman, mimics mastitis, no lump, may pit, turn orange, appear bruised, rare but aggressive breast cancer • Fibrocystic breast- engorged and painful breasts symptoms 2 weeks before menses and at worst before cycle, resolves after menses DX multiple, mobile rubbery cystic masses on both breasts, TX stop caffeine, take vitamin E, IS IT “NORMAL IN AGING/ELDERLY” • BRCA1/2 associated hereditary breast/ovarian Cancer- family history is high risk, Men are higher risk, TX patient positive with BRCA mutation should be referred to breast specialist, MRI and mammogram, high risk in Jews, refer to counseling and mutation testing • Ovarian cancer- palpate ovary in 1-year post-menopausal woman, risk factors include family history, Jewish descent, BRCA1/2 mutation, lynch syndrome, breast cancer, >55 age, endometriosis, first child at age 30, nulliparity(never completed pregnancy past 20 weeks) Dx pelvic exam, transvaginal US, biopsy, Dx intravaginal US, CA124, TX chemotherapy, referral surgical oncology eval and treatment • Pap testing- begins at 21 and every three years till 30 then every 5 years, • UPSTF recommends at age 30 with HPV testing to every 5 years, HIV positive women can screen before 21 years of age, stop PAP screening at 65 • Loop electrosurgical excision procedure (LEEP)- is a device used like a scalpel cut thru cervix to treat cervical cancer. • Potassium hydroxide slide – KOH aids in diagnosing fungal infections hair, nails and skin, KOH works by causing lysis of the squamous cell which makes it easier to see the hyphae and spores, vaginal specimens do not require KOH • Whiff test- test for BV, fish odor is released after dropping KOH on slide • Polycystic ovarian syndrome- hormone abnormality marked by anovulation, infertility excessive androgen production and insulin resistance, high risk for type 2 diabetes, dyslipidemia, metabolic syndrome, endometrial hyperplasia, obesity and cancer, infertility, sleep apnea, hirsutism, acne, amenorrhea, Post menopause with bleed/PCOS- high risk for endometrial cancer • DX transvaginal US, testosterone, FSH, fasting glucose, TX low dose contraceptives, spiraladactone for hirsutism, metformin • Osteoporosis >-2.5 Osteopenia -1.5 to -2.4 • KNOW ELDERLY WITH LIVER AND KIDNY FAILURE WITH SEVERE LUMBAR PAIN PENDING SX HOW DO YOU TREAT HER PAIN • Persistent infection -vaginal and urinary tract infections screened for diabetes • Prostaglandins- responsible for dysmenorrhea PREGNANCY • Immunizations in pregnancy- hepA, Hep B, influenza inactivated), meningococcal, polio, tetanus Tdap (only in 3rd trimester) • Contraindicated Immunizations in pregnancy- oral polio, HPV, flu mist (influenza), MMR (no pregnancy attempt after 28 days of rubella vaccine), Varicella zoster 3 months • Safe Abx in pregnancy- penicillin’s, cephalosporins, macrolides, and nitrofurantoin (not on patients with glucose 6 phosphate deficiency) • Not 100 % safe in pregnancy- ARBS, ACEI, Fluoroquinolone, tetracyclines NSAIDS, Sulfa, • Naegles rule- PLUS 9 months add 7 days • Preeclampsia- primigravida in third trimester, multipara, >35 years old, sudden onset recurrent headaches, blurred vision, pitting edema, weight gain, RUQ pain, shoulder pain, lower back pain, hyperreflexia, decrease in urine output, BP elevated, N/V, occurs after 20 weeks pregnancy induced hypertensive condition, resolves after pregnancy, DX HTN, proteinuria, and edema, , TX hospitalization, antihypertensive medications- methyldopa/aldomet, CCB, labetalol, bedrest, laying on left side recumbent position off of vena cava, seizure precautions, balance diet high intake of protein low salt, antihypertensive, education, only CURE deliver fetus, refer to OB • Eclampsia- seizures or coma in patient with previous preeclampsia • Ectopic pregnancy- caused by idiopathic, PID, IUD, estrogen/progesterone, high risk- 50% no known risk factor, >35 years of age, nonwhite females, PID, endometriosis, previous ectopic pregnancy, IUD, pelvic or tubal surgery, cigarette smoking, infertility, invitro fertilization, leading cause of death for women in first trimester • Threatened abortion-vaginal bleeding, cramping without cervical dilation • Inevitable abortion-vaginal bleeding, cramping with cervical dilation • Incomplete abortion- moderate to diffuse bleeding, passage of tissue, uterine contractions • Hcg in urine pregnancy test- produced by placenta • Alpha feta proteins- produced by fetal liver • Oral contraceptives- 91% effective, , estrogen/progestrin disadvantages- pill daily, thrombophlebitis/embolism, liver adenomas, stroke, gall bladder disease, no std protection, NO smoking may result in cardiovascular side effect, contraindicated in <6- week post-partum, breast cancer, • Contraceptive patch- 91% effective, estrogen/progestrin, disadvantages same as above, patch may fall off and must be reapplied, patch once a week • Contraceptive vaginal ring- 91% effective estrogen/progastrin, insert day after menses, disadvantages- uncomfortable inserting, ring falls out for less than 3 hours, rinse off and reinsert, • Progestin oral- 91% effective, disadvantages taken daily, chance of ectopic pregnancy, • Deprovera- 94% effective, injectable progestin for 13 weeks, disadvantage is bone loss, fertility may not return for 1 year, • Etonogestrel implant- 99% effective, placed subcutaneously in upper arm and releases hormones for 3 years, quick return to fertility, bleeding is side effect • Intrauterine device- Mirena, progesterone, 99.8% effective, disadvantages expel intrauterine device, sepsis, cervical infection, ectopic pregnancy, infertility, • Diaphragm- 88% effective, spermicide, prevents stds, must be refitted, bladder infections, yeast infection, bacterial infection, • Morning after pill- plan B, take within 72 hours of unprotected sex or of 2 days of skipped birth control, take second pill 12 hours later, rule out preexisting pregnancy first • Placenta abrupto- 3rd trimester, sudden onset of bleeding, contracted uterus, feels hard, painful, dark red colored vaginal bleeding, risk factors- smoking, cocaine use, no seatbelt, HTN, TX baby must be delivered to save mothers life c section, refer to ED, CBC, Pt/PTT abdominal US and blood transfusion • Placenta previa- abnormally implanted placenta, multipara in 2nd/3rd trimester new onset of painless bleeding, worsened by intercourse, blood is bright red, uterus is soft nontender, cervix is not dilated TX bedrest, magnesium for cramping, vaginal or rectal insertion is contraindicated, if cervix is dilated or hemorrhaging, fetus must be delivered c section to save mothers life, refer to ED, no bimanual examinations, abdominal US only, • Positive sign of pregnancy- palpation of fetus by provider, US and visualization of fetus, fetal heart tones 10 -12 doppler, 20 weeks stethoscope • KNOW ABOUT FUNDAL HEIGHT NOT MATCHING UTERINE GROWTH HOWTO VERIFY • Probable sign- goodell sign-cervical softening, Chadwick sign- blue coloration of cervix/vagina, hegar sign- softening of uterine isthmus, enlarged uterus, ballottement, Urine /serum pregnancy Beta HcG is in molar pregnancies and ovarian cancer • Presumptive sign- quickening, amenorrhea, N/V, breast changes • S3 heart murmur -normal in pregnancy • Chloasma/meloasma- due to high estrogen • Jews- screened for Tay sachs disease • Obstetric history- GTPAL gravida-number of Prego’s, term-number carried past 37, preterm- number carried till 20 weeks, abortion- deliveries before 20, living- number of living children • Uterine involution –(prepregnant state) takes 6 weeks • RhoGam – give to all Rh-negative mothers at 28 weeks then 72 hours after delivery, destruction of Rh positive fetal RBC’s presenting in mom’s circulatory system • Coombs test is used to test for autoimmune hemolytic anemia, positive direct coombs (infant)test means you have antibodies that act against your RBC’s, Indirect coombs test is for mother, coombs test can also tell us if there is high bilirubin watch for anemia and jaundice • Gestational diabetes- high risk for developing type 2 diabetes, neural tube defects, congenital heart disease, birth trauma, eclampsia, Risk factors are previous pregnancy, obesity, ethnicity, DX Screen at first visit or 24-28 weeks gestation, one step is 75g OGTT (screening and diagnosis), 2nd step is 50 OGTT nonfasting (screening), if abnormal follow up with 100 OGTT (fasting) TX lifestyle change • Chadwick sign- bluish coloration of cervix • Hegars sign- softening of cervix • Diabetes in first trimester is type 2 diabetic • Asymptomatic bacteriuria- high risk for pyelonephritis Dx urine C&S, urine dipstick, refer to ED if pyelonephritis TX nitrofurantoin, Augmentin, cephalosporin, no sulfa • UTI -in pregnancy is 10x3 not normal 10x5 • Fundus at 12 weeks is above synthesis pubis • Fundus at 16 weeks is between the synthesis pubis and umbilicus • Fundus at 20 weeks is at the umbilicus • Swallowing noises-during breast feeding is normal but not clicking noises • Breastfeeding mastitis- common in first 2 months, skin fissures on nipples, staph or MRSA pathogen, flu like symptoms malaise, adenopathy in the axilla of affected breast, if severe refer to ED, prevent by frequent and complete emptying, DX clinical diagnosis, CBC shows leukocytosis, Milk C4S, TX dicloxacillin or cephalosporin, if MRSA treat with Bactrim or macrolide PEDIATRICS • Kolpik spots- are a prodromic viral enanthem of measles manifesting two to three days before the measles rash itself. They are characterized as clustered, white lesions on the buccal mucosa (opposite the lower 1st & 2nd molars) and are pathognomonic for measles. • Encopresis- repetitive soiling of stool of child 4 years old or greater • Satellite lesions- The term is commonly used to describe a portion of the rash of cutaneous candidiasis in which a beefy red plaque may be found surrounded by numerous, smaller red macules located adjacent to the body of the main lesions. • Hirschsprung disease- A condition of the large intestine (colon) that causes difficulty passing stool.in first 48 hours of life, meconium • Bronchiolitis- Bronchiolitis is almost always caused by a virus, no abx, treat with antipyretic • Pneumonia- penicillin • Atypical pneumonia- azithromycin • Diarrhea - in children, common bug is rotavirus • Lyme disease in , <8 years children- TX azithromycin, clarithromycin, ceftriaxone Newborns • Anterior fontanels close at 9-18 months • Posterior fontanels close at 3 months • Breast fed infants require vitamin D supplement for days of life • Breast milk- consists of 20kcal/30ml, Lactose • Fragile X disorder- long narrow face prominent forehead/chin, large ears, intellectual disability, autistic disorder • Failure to thrive- weight that falls below 3r to 5th percentile, causes diarrhea, dietary intake, malabsorption, (celiac disease, cystic fibrosis, food allergy) poor maternal bonding, frequent infections, • Down syndrome- genetic defect trisomy of chromosome 21, most common chromosomal disorder, avg life span 60, round face appears flat, upward slanting eyes, low set ears, chronic open mouth caused by enlarged tongue, short neck, broad hands, newborns have hypotonia and poor Moro reflex, high risk of congenita heart defects, hearing loss, visual problems, cataracts, sleep apnea, early onset of Alzheimer’s, educate parents about high risk sports and avoid trampoline • Fetal alcohol syndrome- small head with narrow eyes flat nasal bridge, thin upper lip, ears are underdeveloped, mild to severe mental retardation, not obvious till adolescence, alcohol is prohibited during pregnancy affects CNS, somatic growth and facial structure • Cryptorchidism- a testicle that has not moved into the bag of skin below the penis before birth, maybe one or two, increases risk of testicular cancer, TX order US, corrected surgically • Gonococcal ophthalmia neonatorum- symptoms 2-5 days after birth, cause blindness, red conjunctiva, profuse purulent discharge and swollen eyelids, normally acquired during delivery, if positive acute conjunctivitis test for several STD’s, order gonococcal culture (Thayer-martin) herpes culture, chlamydial PCR, TX ceftriaxone, topical erythromycin ointment, Test and treat mother and partner • Chlamydial Ophthalmia neonatorum- symptoms 4 to 10 days eyelids are edematous, red and profuse watery discharge, and later becomes purulent, Test exudate and conjunctival cells, TX azithromycin IM or oral erythromycin, prophylaxis is topical erythromycin ointment or tetracycline ointment, Test and treat mother and partner, reportable disease • Chlamydial pneumonia- nasopharyngeal culture, frequent cough, bibasilar rales, tachypnea, hyperinflation, diffused infiltrates on cxray, TX erythromycin reportable disease • Sudden infant death syndrome- unexpected death in infants under 12 months, higher risk with premature, low birth weight, maternal smoking or drug use, poverty, decrease risk by position infant’s supine, avoid side lying or prone positions, avoid overheating infant with thick quilts • Weight loss -beyond 7% is abnormal in infants • Dehydration- >10% weight loss, weak rapid pulse, tachypnea, deep breathing, parched mucous membranes, anterior fontanelle is sunken, tenting, cool skin , anuria, change in LOC, refer to ED for IV fluids, severe dehydration due to gastroenteritis leading cause of death in the world, HOW DO YOU ASSESS, OPTIONS: SKIN, WEIGHT, POSTERIOR FONTANEL, DON’T REMEMBER LAST OPTION • Mongolian spots-blue to black covered patches, mistaken for bruising or child abuse, fades 2 to 3 years • Milia, Miliaria, prickly heat- multiple white papules located mainly on forehead cheeks and nose, due to retention of sebaceous material and keratin, resolves spontaneously • Erythema Toxicum Neonatorum- small pustules surround by red base, erupts during 2 or 3rd day of life lasts 1to 2 weeks resolves • Seborrheic dermatitis (cradle cap)- excessive thick scaling on scalp, TX softening and removal of the thick scales after soaking in vegetable or mineral oil, shampoo scalp and gently scrub scales with soft comb, self-limited condition that resolve spontaneously in a few months • Faun Tail nevus- tufts of hair overlying spinal column usually at lumbosacral area, maybe sign of neural tube defect spina bifida, perform neurological exam focus on lumbosacral nerves order US of lesion to rule out occult spina bifida • Café au Lait Spots- flat light brown to dark brown spots > 5mm, if 6 or more > 5mm rule out neurofibromatosis, or von Recklinghausen’s disease (neuro disorder- seizures learning disability) refer to pediatric Neurologist • Port wine stain (nevus flammeus)- neonates with pink red flat stain like skin lesions upper/lower eyelid or v1, v2 branches of trigeminal nerve, refer to pathologist to rule out congenital glaucoma, blanches to pressure, irregular size, lesions do not regress and grow with child • Hemangioma (strawberry Hemangioma)- raised vascular lesions ranging in size from .5 to 4.0 cm, bright red and feel soft to palpation, head and neck area, grow during first 12 months, resolve spontaneously, watchful waiting strategy, can treat with PDL therapy (laser) • Strabismus- misalignment of the eye, • Hirschberg test is screening for strabismus • Estropia- inward turning of the eye • Exotropia- outward turning of the eye • Amblyopia- lazy eye • Gross hearing test- response to loud noise • HEARS-high risk factors for hearing loss, hyperbilirubinemia, ear infections, Apgar score low at birth, rubella, seizures • Lead screen -at 1 to 2 years old • Required screens- PKU, sickle cell, TSH • Nutrition- Breast feed is preferred supplement with vitamin D, or formula fortified with iron • Cow’s milk- avoid first year of life, causes GI bleed and IDA • Solid foods- 4 to 6 months with rice fortified with iron • Caput succedaneum- diffuse edema of scalp crosses midline, caused by intrauterine and vaginal pressure from prolonged or difficult vaginal labor, scalp is molded, or cone shaped, resolves spontaneously, ecchymosis of scalp, scalp edema • Cephalohematoma -traumatic subperiosteal hemorrhage, rule out skull fracture, swelling does not cross midline or suture line • Head circumference - avg 35cm, measure at each wellness till 3 years old, head circumference 2 cm bigger than chest, increase by 12 cm in first year • Hypospadias- urethral opening is underside of penis instead of normal placement • Epispadias- urethral meatus is upper side of penis • Neonates -weight loss 5 to 7 % after birth regain in 2 weeks • Birth weight -doubles by 6 months and triples in 12 months • Epstein pearls- white papules found on gum line resembles erupting tooth • • Teeth- first full set of teeth at 2.5 years old, permanent teeth at 6 years old • Anal wink- abnormality could indicate spina bifida • Plantar reflex (Babinski reflex)- upward extension of big toe with fanning of other toes • Palmar reflex (grasp reflex)- place finger in infant’s hand, pull away infant’s hand grip tightens • Moro reflex- (startle reflex)- disappears by 3to 4 months, absence on 1 side rule out brachial plexus injury fracture, absence both sides rule out- spinal cord/brain lesion, older infant with continued more reflex rule out brain pathology • Step reflex-baby foot touches flat surface, will flex hip and knee on surface, abnormal with paresis or breech births disappears 6 weeks • Blink reflex-eyelids close to light or response • Tonic neck reflex (fencing reflex)-turning head to one side with jaw over shoulders cause arm and leg to extend, the arm and leg on opposite side will flex, disappears by 6 months • Rooting reflex-stroking corner of mouth causes baby to turn toward stimulus and suck, disappears by 3 to 4 months • Immunization birth to 6 years old Hep b – birth and 2 months Rotavirus – 2,4, 6,months DTAP- 2,4,6,16, 18 months, 4 years old Hib influenza- 2,4,6,12 months Pneumonia pcv4 – 2,4,6,12, 15 months IPV- 2,4,6,18,months 4 years old MMR- 12 months 4 years old Varicella- 12 months 4 years old Influenza - 6 and then annually • Jaundice -at birth first day of life or full-term infant, TX first line is phototherapy, bilirubin lab, complication is kernicterus- bilirubin circulation damages CNS • Physiological anemia of infant- temporary decrease of H&H by kidney erythropoietin • Congenital lacrimal duct obstruction (dacryostenosis)- spontaneously resolves in 6 months • Acute dacryostenosis- redness warmth tenderness and swelling of one lacrimal duct, complication of orbital cellulitis, TX lacrimal sac massage, culture discharge and TX with systemic Abx, • Infant colic- rule out conditions cause pain, discomfort, infection, environment and formula allergy resolves 3-4 months • Coaction of aorta- narrowing of the large blood vessel that leads from the heart, systolic BP on lower extremities is supposed to be higher compared to upper extremities, DX COA its vice/versa (weak radial pulse and bounding femoral pulse) CAUSED BY CONGENITAL HEART DEFECT, order echocardiogram, ekg, cxray • Developmental dysplasia of the hip (DDH)- asymmetry of creases of the legs, high risk breech births, female gender, family history, oligohydramnios, check gluteal popliteal hip to match, TX order US of hips, refer to pediatric orthopedist • Ortaloni maneuver test- rotate hips in frog leg position abduction adduction, if click or clunk sound or palpable trochanter becoming displaced • Barlow maneuver - is pushing both knees together midline downward and upward, click or clunk or palpable trochanter being displaced by index/middle finger • Galeazzi sign- one femur appears shorter when infant is supine • Intussusception-obstruction of the intestines, cuts off blood supply, fatal, sudden loud crying, comes/goes, vomiting, blood/mucus mixed with stool, SAUSAGE LIKE MASS Toddlers 2-3 • Rolls both directions back to back 6 months • Plays peek a boo, patty cake, and (cruise) walks by holding onto furniture by 9 months • Speech at 2 understood by family • Speech- at 3 understood by strangers • Ride -tricycle at 3, bicycle at 6 • 3-year-old -Copy a circle • 4-year-old -can copy a cross • Oedipal stage 3-6- child expresses to marry parent of opposite sex • 4 years old- Draw stick person with 3 body parts • 5 years old- Draw tick person with 6 body parts • Neuroblastoma- painful abdominal (retroperitoneal or hepatic) mass that is fixed firm or irregular and frequently crosses the midline, common site is the adrenal medulla, patient present with Metz disease, weight loss fever, Horner’s syndrome ( miosis, ptosis, anhidrosis) racoon eye, bone pain, HYN, diagnosed in children 1 to 4, elevated urinary catecholamines and anemia, Dx US of the abdomen, refer to nephrologist • Wilms tumor (Nephroblastoma)- renal malignancy, crosses midline congenital tumor of kidneys, common in African American girls, asymptomatic abdominal mass extends from the flank toward midline, nontender smooth mass abdominal pain, hematuria, HTN, 2-3 years old, palpate with rupturing mass Dx US abdomen • Epiglottis- acute and rapid onset of high fever chills and toxicity, sever sore throat, drooling, not eat to drink, hot potato voice and anxiety, sitting posture with hyper extended neck, open mouth breathing stridor, tachypnea/cardia, 2 to 6 years old, prophylaxis rifampin, reportable disease call 911 rare due to Hib vaccine • Osteomyelitis- common in infants/children- infected bone or joint is red swollen, warm and tender to touch, febrile and irritable, walks with limp, infection in hip, knee or leg, results in growth stunting of the affected limb, refer to hospitalization for high dose Abx • Orbital cellulitis- abrupt onset of deep eye pain high fever, chills, aggravated by eye movements, bulging eye, abnormal extraocular exam movements due to infection of the ocular fat pads and muscles. Ethmoid sinusitis is cause, can be life threatening, serious complication of rhinosinusitis, acute otitis media, or dental infections refer to ER CT or MRI scan in ED • Pretectal cellulitis (periorbital cellulitis) infection of anterior portion of the eyelid does not involve orbit or globe of eye, rarely causes complications, red swollen eye pain, eye movements are normal refer to ED • Child abuse- 1. Parents, 2. daycare staff and unmarried partners, 3. Relatives • Death 1 to 4- 1. accidents or unintentional injuries, 2. congenital anomalies, 3. assault • Cancer in children- 1. leukemia (acute lymphocytic leukemia ALL), 2. Brain and nervous system tumor, 3. Neuroblastoma • Toilet training- ready by 2, mastered by 3to 4, abnormal if not done by 5 • Car safety- 40 lbs. can sit facing forward • Autism- developmental disorder of development social skills and communication skills, signs begins at 18 months, not point wave or grasp by 2, no babbling or coo in 1 year no single word by 2, not say two word on own by 2, loss of language or social skills by 2, does not gesture wave, grasp or point by 2, TX refer to psychiatrist for testing, intense rehab OT/PT, Medications Risperdal (antipsychotic) School-age • Leukemia- extreme fatigue, weakness pale skin easy bruising, petechial bleeding, bleeding gums, nose bleed, bone or joint pain, lymphadenopathy, swelling in abdomen, common type is ALL • Acute lymphocytic leukemia- fast growing cancer of immature lymphocytes, CBC show high WBC >50,000, girls high chance of cure, African /Hispanic low cure rate • Acute myelogenous leukemia- (AML) fast growing cancer in bone marrow affects immature or precursor blood cells myeloblasts (WBC), monoblasts (macrophages) erythroblasts (RBC), megakaryoblasts (PLT), children with down syndrome have better cure rates if < 4 years old • Reyes syndrome- febrile illness chicken pox, influenza, or aspirin salicylate (Pepto bismol) intake, abrupt onset and quick progression, death can occur in hours to days mortality of 52%, disease is rare • Absence seizure- petit mal seizure, brief episode of child staring, common type of pediatric seizure refers to pediatric neurologist • KNOW Simple partial seizure are localized to one area on one side of the brain, but may spread from there Motor – A simple partial seizurewith motor symptoms will affect muscle activity, causing jerking movements of the foot, face, arm, or another part of the body. • Still’s murmur- benign systolic murmur having vibratory or musical quality, louder in supine position or with fever, minimal radiation grade 1-2 intensity, most common in school age, resolves in adolescence • Atlantoaxial instability -(down syndrome) instability of c1 and c2 • Marfan’s syndrome- aortic aneurism risk, lens eye displacement, joint hypermobility • Death- 5 to 14- accidents/unintentional injuries, cancers, genetic condition • Autism- developmental disorder of development social skills and communication skills, TX refer to psychiatrist for testing, intense rehab OT/PT, Medications Risperdal (antipsychotic) • Fragile X syndrome- large head circumference and mental retardation, delayed physical development milestones such as crawling walking, autism is common, hyperactive behavior, long face with prominent forehead jaw and large ears, large body with flat feet TX refer for genetic testing, refer to psychiatrist • Meningococcal vaccine, HPV, Tdap- vaccinate 11-12years old • HPV- youngest age is 9 to receive • 11-year-old- early abstract thinking stage (Piaget) • Death small kids- leading cause are MVA, suffocation, drowning, poisoning, fire and burn Adolescents • Acetaminophen poisoning- stage 1 N/V, lethargy malaise, Stage 2 RUQ pain, elevate LFT, Pt, INR, nephrotoxicity, pancreatitis, deaths occur in 72 to 96 hours TX Antidote is N-acetylcysteine IV • Testicular torsion- abrupt onset extremely painful and swollen red scrotum, N/V, affected testes higher and closer to body, the cremasteric reflex is missing, >not corrected in <6 hours permanent damage, if not corrected in 24 hours becomes gangrene, common in males with bell clapper deformity Dx call 911, US doppler preferred test, manual reduction or surgery, elevated PSA, biopsy of prostate tissue, PSA level with DRE TX refer to urologist, individualize screen per risk factors • Testicular cancer- hard fixed, nodule, heaviness or aching, one testicle larger than other, hydrocele from tumor, painless asymptomatic until Metz, Dx, Gold standard testicular biopsy, US of testes, refer to urology, for surgical removal (orchiectomy) • Hodgkin’s lymphoma - cancer of b cells (Reed Sternberg cells), pruritic, painless supraclavicular lymph nodes with fever (pel-ebstein sign), night sweats, fever, pain with alcohol drinks, young adults • Death adolescents- MVA suicide, homicide • Tanner 2- female breast bud areola develops Male testes scrotum start to enlarge, scrotum gets darker • Tanner 4- female nipples and areola become elevated from breast, secondary mound Male penis grows wider grows in length, darker scrotum • Menarche- starts at age 12, irregular periods for several months up to 2 years • Dysmenorrhea- TX heating pads, NSAIDS • Emancipated minor- minors give full consent without parental involvement 1. Legally married, 2. Active duty armed forces • Right to consent confidentiality- 1. contraception, 2. TX STD’s,3. Diagnosis and management of pregnancy • Primary amenorrhea-no menarche at 15, chromosomal disorder (turner syndrome), Secondary amenorrhea- no menses for three cycles or 6 months, due to pregnancy, ovarian disorder, stress, anorexia PCOS Dx pregnancy test, prolactin level, TSH FSH, LH, bone density TX educate caloric intake calcium and vitamin D 1200 to 1500 daily, refer to pediatric endocrinologist • Anorexia nervosa- onset during adolescence, irrational preoccupation with fear of gaining weight, patient engages in restriction (diet, exercise) or binge eating and purging (laxatives, enemas, diuretics, vomiting).DX weight loss >10% body weight loss or <18.5 BMI low pulse vital signs unstable, hypotension, lanugo, stress fractures, swollen feet (low albumin), dizzy, bloating • Deprovera- increase risk of bone loss • Gynecomastia- excessive growth of breast tissues in males, one or both breasts, resolve spontaneously, round rubbery mobile mound under areola of both breasts TX eval tanner stage, check for drug use, rule out etiology, recheck in 6 months • Pseudo gynecomastia- bilateral enlarged breast is due to fatty tissue (adipose tissue), common in obese boys, soft tissue nontender no breast bud or disc like breast tissue is palpable Dx clinical presentation • Adolescent idiopathic scoliosis- lateral curvature of the spine accompanied by spinal rotation, painless, asymptomatic, rapid worsening of curvature is indicative of secondary cause, Dx Adams forward bend test, check height, measure cobb angle, full spine x-ray to measure degree of curve, TX if <20 degrees observe and monitor, >20 bracing (Milwaukee brace), >40 surgical correction, Harrington rod used on spine refer to pediatric orthopedist • Osgood-Schlatter- occurs during growth spurt and affects superior tibia, when quadriceps exert stress on the patellar tendon (tibial tubercle), anterior knee pain increases over time TX resolves spontaneously rule out avulsion fracture, if acute order lateral x-ray of knee, avoid aggravating activities, RICE ETHICAL GUIDLEINES AND ADVANCED PRACTICE LAW • Beneficence- obligation to help patient, to remove harm, to prevent harm, promote good, “do no harm”Ex. Educating patient about new prescription, how to take, encourage to stop smoking, calling surgeon to get prescription stronger • Nonmalificence- obligation to avoid harm, protect a patient from harm, prescribing a medication that is not contraindicated to patient • Utilitariasm- obligation to act in way that’s useful to or benefits the majority, outcome is what matters with utilitarism, use resource to benefit the most, Ex WIC is only for women and babies because it would cost society more if these patients were hurt by inadequate food intake • Justice-quality of being fair without acting with a lack of bias, fair suitable distribution of resources, ex homeless man admitted to ED without insurance, treated the same as a man with insurance • Dignity- quality or state of being worthy of ethical and respectful treatment respect for human dignity is important aspect of medical ethics, persons religious, personal, cultural beliefs are considered dignified treatment Ex. Using hospital gowns to cover patient front and back, Foley catheters should not be visible to visitors not to embarrass patient • Fidelity-obligation to maintain trust in relationship- keeping promise, dedication and loyalty to patient, Ex. NP should try her best to develop trust with patient • Confidentiality-obligation to protect patient’s identity, personal information, test results, medical records, conversations, and other health information is right is protected by HIPPA • Autonomy-obligation to ensure mentally competent patients have right to make their own health decisions and express treatment preferences • Accountability- NP are responsible for their own actions and choices and do not blame others for their mistakes Ex. Patient diagnosed with pleurisy but when goes to ED is diagnosed with MI, no error is held accountable for her decision • Veracity- obligation to present information honestly and trustfully, in order for patient to make informed decision, do not withhold “bad news”, Ex. Patients mammogram results are in, but son does not want patient to know, no must tell patient • Paternalism- one person interferes or overrules the autonomy of another • Ombudsman- person who acts as intermediary between patient and organization, ombudsman investigates and mediates complaint form both sides and attempts to reach fair conclusion • Guardian ad litem- person assigned by court to act in best interest of the child/frail vulnerable patient. • TPA- organization that does processing of claims and administrative paperwork for another company • Medicare A pays for inpatient services, (Hospice) • Medicare B pays for outpatient services (ambulance emergency only) • Medicare C pays for both • Medicare D is for medications drug benefit • Medicaid -provides insurance for low income individuals and families who meet poverty criteria • HMO-patients assigned PCPC (gatekeeper),copay per visit, PCP must approve referral • PPO-not assigned PCP, can visit any PCP, more expensive than HMO • Medicare B does not reimburse for dentures glasses or hearing aids or ambulance transportation • COBRA- is law that allows person to keep insurance after quit job • Medical home- primary healthcare delivery of PT/OT/speech, communicate thru phone, video chat or email. PROFESSIONAL ROLES AND REIMBURSEMENT • State nurse practice act – “right to practe”enacted into law by state legislature • State board of nursing- responsible for forcing state nurse practice act • Title protection- titles protected by law • Standard of profession nursing practice- developed by professional societies • Collaborative practice agreements- written agreement between supervising physician and NP • Situational leadership- flexible, can adjust his or her leadership style • Transformational leadership- ability to communicate vision to staff • Laissez-Faire Leadership- minimal supervision or direction of staff • Authoritarian Leadership- like control and structure • Democratic leadership- likes more staff meeting for input from staff • Servant leadership- likes to work along staff • Malpractice- duty is owed, duty was breached, breach caused injury, damage occurred • Problem focus visit- chief complaint, HPI, no ROS or past family/social history needed • NPI- contains 10 numbers/digits • ICD 10 code- diagnosis codes • CPT codes bill outpatient office procedures and services • Incident to – billing is used for Medicare patients and refers to billing follow up visit performed by non-physician provider billed under physicians NPI#, nonphysican is paid 100% vs the rate of an NP who receives 85% • Insurance- considered third party NURSING RESEARCH REVIEW • Primary prevention- prevent disease or injury before it ever occurs (diet, exercise, gun locks, seatbelt, bike helmets, education eating well, OSHA, EPA, build youth center, habitat for humanity, aspirin who have risk , not smoking, immunizations) • Secondary prevention- reduce the impact of a disease by detecting or treating the disease to halt or slow progress (regular exams, screening tests, (paps, cbc, cage, interview for depression or sex partners, test for hep C) low dose aspirins exercise to prevent further attacks, modify work so injured people can work safely • Tertiary prevention- soften the impact of ongoing illness or injury lasting effects, manage long term effects of chronic illness/permanent impairments (cardiac stroke rehab, diabetes, depression, arthritis, support groups, vocational rehab • Control group- - subjects in an experiment who do not receive treatment • Prospective study- studies done in the present to the future data obtained in present and periodically measured in the future • Retrospective study-(ex post facto) studies done on events that have already occurred(chart reviews, recall of events • Longitudinal study-long term study that follows same group or subjects over many years to observe measure and compare same variables over time Ex. Framingham Heart study followed group to monitor CVD • Cohort study- group individuals share common characteristics such as gender job, ethnicity, studying causative factors or risk factors Ex study of nurse’s long term who taken oral contraceptives • Cross sectional study- compares differences and similarities between two or more groups of people or phenomena and collects data at one point in time • Case control study- in depth investigation of a single person, group or phenomena • Experimental study- use randomization with subject selection • Correlational studies (observational) -search for relationship between minimum of two variables • Deductive logic- used in quantitative studies • Inductive used in qualitative studies • Institutional review boards IRB’s - ensure rights, safety and welfare of human research subjects, purpose to protect the rights of human subjects enrolled in a study • Normal curve- is the bell curve • N-total number of subjects • n-subgroup EVIDENCED BASED MEDICINE • Loretta Ford- created 1st NP program • Metanalysis- combines data from multiple studies resulting in higher statistical power and single conclusion, gold standard for research evidence in EBM • Systematic review-literature review that identifies selects, analyzes research articles concerning health condition disease or practice, • Randomized control trial-(experimental study)- subjects assigned to control or treatment group, experimental study (double blind design (no one knows who is being treated)) • Experimental study- experiment involves random subject selection, one placebo one controlled and one intervention, see above RCT • Quasi experiment- convenience sampling instead of random sampling • Cohort study- used to investigate risk factors of a disease, death or other conditions, subjects observed for long time, no intervention, goal is to find risk factors not causation (can be a prospective study of now to future)) • Case report-detailed report of one patient with disease or unusual condition, that includes demographics, signs symptoms, diagnosis, response to treatment • Case series- series of case reports involve several individuals who are given similar treatment • Opinions/editorials-biased and not based on solid evidence, weakest evidence • Sensitivity- the ability of a test to detect a person who has the disease true positive • Specificity- the ability of a test to detect a person who is healthy or detect the person without the disease true negative • Horizontal transmission- Ex sex transmitting HIV • Vertical transmission- mother transmitting HIV to fetus • Endemic- baseline particular disease, • Epidemic rapid increase involving large number • Pandemic- large are countries continents DRUGS KNOW ALL THESE ARE TRICKY • Beta blockers- contraindicate in asthma/copd//emphysema, masks signs of hypoglycemia, bradycardia, exercise intolerance, fatigue • CCB- side effect is edema in ankles, arrhythmias, hypotension, headache, dizziness, constipation, flushing, weakness, migraine prophylaxis, drug reaction with grapefruit, preferred for isolated systolic hypertension • ARBS/ACEI- lower Hgb levels in pts with chronic diseases preferred in CHF/diabetes patients, asses renal function, avoid in renal stenosis, hypotension, hyperkalemia • Atorvastatin- perform liver function tests, side effect myalgias, myopathy, rhabdomyolysis. Contraindicated with grape fruit juice • Thiazides- largest studied drug, lowers potassium, increases gout, increase digoxin toxicity • Spironolactone- side effect of gynecomastia • Diuretic side effects- hyperglycemia, hyperuricemia, hypertriglyceridemia, hypokalemia. Hyponatremia, hypomagnesemia • Butterburr- for headaches • Ginko bilba- help with memory, circulatory disorders, contraindicated with aspirin/warfarin • Saw Palmetto for BPH • St John Wort- for depression and menopause symptoms • Kavakava/valerian root- anxiety or insomnia affects liver • Ginseng- reduce stress, weight loss, sexual dysfunction, lower blood sugars • Ginger= anti-inflammatory • Feverfew- migraines and menstrual cramps • Echinacea- builds immunity • Aspirin- effect on platelets irreversible 15- 20 days, monitor for bleeding, tinnitus, tarry stools, GI irritation • NSAIDs- affect GI, renal, cardio, blunts diuretics • Ponstel (Mefenamic acid) is an NSAID for menstrual pain • Macrobid/nitrofurantoin- long term use associated with lung, hepatitis, renal insufficiency, and neuropathy • Metformin – affects liver enzymes, weight loss, avoid in alcohol drinkers, watch for lactic acidosis, diarrhea and flatulence • Steroids- side effects osteopenia, cataracts • Potentially inappropriate drugs for elderly-Benadryl, glipizide, glyburide, benzodiazepines, thioridazine, mesoridazine, Seroquel, Zyprexa, Elavil, trofanil, NSAIDS, Ambien, Reglan, mineral oil, PPI’s • Potentially inappropriate drugs for pregnant females -Tetracyclines, sulfa is iffy, fluoroquinolones, ACE, NSAID, aspirin, any hormonal drugs, Accutane,