Fitzgerald Exam Review

Acute rhinosinusitis

Inflammation of the mucosal lining of nasal passages and paranasal sinuses lasting up to 4 weeks Green nasal exudate = lymphocytes have invaded Typically caused by viruses

Allergic rhinitis

Inflammatory, IgE-mediated disease due to genetic and environmental interactions, characterized by nasal congestion, rhinorrhea, sneezing, intraocular and nasal itching

How is legionella spp. transmitted?

Inhaling mist or aspirating liquid that comes from a water source contaminated with Legionella No evidence for person-to-person spread of the disease

Quad screen results in NTD

Inhibin A: normal AFP: Increased HCG: Normal uE3: Normal

Quad screen results for Trisomy 21

Inhibin-A: normal AFP: Decreased HCG: Increased uE3: Decreased

Are PPIs CYP450 2C19 inhibitors or inducers?

Inhibitors

You have a patient present with new onset CN VII deficit. What is the most appropriate next step in Matthew's care?

Initiate a course of PO corticosteroids Does not need to see neuro Can also check for Lyme

What is the responsibility of the primary care NP when a patient presents with a new thyroid nodule?

Initiate evaluation Refer for appropriate consultation for additional diagnostics, including lesion biopsy

Adverse effects of PCSK9

Injection site reactions RTA Flu like symptoms

Pharmacologic management of gestational diabetes

Insulin Sulfonylureas Metformin

Metformin MOA, efficacy

Insulin sensitizer (no effect on insulin secretion) High efficacy

Patient centered medical home

Integrates patients as active participants in their own health and well-being, and are cared for by clinicians who coordinate all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology

Efficacy of DPP-4 inhibitors

Intermediate

Efficacy of SGLT2 inhibitor

Intermediate

S/s of Epididymoorchitis

Irritative voiding symptoms Fever Painful swelling of epididymis and scrotum Infertility potential

S/s of acute bacterial prostatitis

Irritative voiding symptoms Suprapubic, perineal pain Fever Tender, boggy prostate Leukocytosis

S/s of PID

Irritative voiding symptoms Fever Abdominal pain Cervical motion tenderness Vaginal discharge

S/s of chlamydia trachomatis

Irritative voiding symptoms, occasional mucopurulent discharge Cervicitis common Often w/o symptoms in either gender Large # of WBCs

Common complaints in genitourinary syndrome of menopause AKA atrophic vaginitis

Itching Burning Often without symptoms

Jock itch vs. genital candida albicans in a man

Jock itch is caused by fungal dermatophyte infection - does not affect scrotum or glans Candida albicans is yeast

ACE-I adverse effects

K+ sparing Risk of hyperkalemia with inadequate fluid intake, renal impairment esp. when used with aldosterone antagonist ACEI-induced cough Angioedema (esp. man of African ancestry) Pregnancy category D

ARB adverse effects

K+ sparing, hyperkalemia risk esp. when used with aldosterone antagonist Some angioedema risk (less than ACE) Do not use during pregnancy, category D

Anterior uveitis (AKA Iritis)

Keratic precipitates present in the cornea Posterior synechiae in the iris Pupil constricted, nonreactive, irregularly shaped with perilimbal injection

What diagnosis should you consider if a tall male patient presents with small testes and gynecomastia?

Klinefelter's syndrome (XXY)

What position should you place the patient if you are unable to palpate PMI

L later decubitus position

Medications for COPD Patient Group D (high risk, more sxms) GOLD 3-4

LABA (salmeterol) + LAMA (spiriva) on a set schedule

Medications for COPD Patient Group C (high risk, less sxms) GOLD 3-4

LAMA (titrotrobium) on set schedule

Medications for COPD Patient Group B (Low risk, more sxms) GOLD 1-2

LAMA (titrotropium/spiriva) or LABA (salmeterol) daily

What labs should you monitor if a patinet is on PTU or methimazole?

LFTs - acute hepatic failure

Management of IBS

LIfestyle modification Avoidance of FODMAPs Medications as indicated by sxms: antidiarrheals, promotility agents, select antimicrobials, probiotics

Prophylactic medications for cluster HA

LIthium

Management of severe dehydration

LR IVF; boluses 20 mL/kg until improvement, then 100 mL/kg over 4 hours

What BP medication should be given to decrease the BP in a pregnant woman?

Labetolol (first line) Nifedipine Methyldopa

Serum sepsis markers

Lactate Procalcitonin

Normal microscopic exam of vaginal discharge

Lactobacilli

Schedule V drugs

Lamotil

What do large S and R waves indicate?

Large L ventricle

Components of metabolic syndrome

Large waistline Hypercholesterolemia Low HDL cholesterol High BP High glucose

Treatment for "wet" macular degeneration

Laser treatment for ophotocoagulation to obliterate neovascular membrane Intravitreal injection of anti-vascular growth factor

S/s of tension-type headache

Lasts 30 minutes-7 days (usually 1-24h) Pressing, nonpulsatile pain Mild-moderate Bilateral 0-1 of: nausea, photophobia, phonophobia Female: male ratio 5:4

S/s of migraine without aura

Lasts 4-72h w/ >2 of the following characteristics - Unilateral location - Pulsating quality (mod-severe) - Aggravation by normal activity During headaches, note >1 of the following - Nausea/vomiting - Photophobia - Phonophobia Female: male ratio 3:1 + FHx in 70-90%

Plumbism

Lead toxicity

Greatest metastatic risk for squamous cell carcionma

Lesion on lip, oral cavity, genetalia

Secondary skin lesion

Lesions altered by outside manipulation, treatment, natural course of disease; crust that develops when vesicles rupture

Age related changes in the older adults

Less % body weight as water >20% lean muscle mass reduction Increase in body weight as fat Decrease in serum albumin (3.8 g/dL is average in older adult as compared to 4.7) Kidney is 80% weight Hepatic blood flow 55-60%

M. Catarrhalis

Less common pathogen in ABRS, AOM, uncommonly CAP Gram - concussion Causes 16% of ABRS in adults >90% are penicillin resistant via beta-lactamase production

Thiazide diuretics and GFR

Less effective with GFR <30 Loop diuretics like lasix remain effective with lower GFR

What WBC change consistent with viral illness?

Leukopenia with lymphocytosis

2nd generation controller therapy for AR

Leukotriene modifiers (montelukast) Best as add-on therapy if symptoms not adequately controlled with intranasal corticosteroids

Management of epididymoorchitis in men >35 or insertive partner in anal intercourse

Levofloxacin 500 mg PO QD or ofloxacin 300 mg PO BID x 10 days

Management of high TSH and low free T4

Levothyroxine 1.6 mcg/kg/d in adults 1.0 mcg/kg/d in elderly Do not take with food or within 2 hours of calcium, iron, aluminum, mag, etc.

Lichen planus

Lichen planus occurs when the immune system mistakenly attacks cells of the skin or mucous membranes. On skin, lichen planus appears as purplish, itchy, flat-topped bumps. On mucous membranes, such as in the mouth, it forms lacy white patches, sometimes with painful sores.

Level 1 visit 99211

Lowest level of care; presenting problems are minimal Ex. patient lost a prescription and needs a new one; patient wants to see if glucose monitor is accurate

#1 cause of cancer death in the US

Lung and bronchus

Pathogens associated with bacterial bronchitis

M. pneumoniae, C. pneumoniae, B. pertussis***

TB Booster phenomenon

Often seen in individuals who have previously been infected with TB — will have initial negative TST but a positive TST when retested up to 1 year later because the first test "boosts" the immune system

Onset of action, peak, duration for regular acting insulin

Onset: 30 minutes Peak: 2-3 h (most likely when hypoglycemic episode can occur) Duration: 3-6h

Components of patient competency

Patient must have the ability to communicate a choice, understand the relevant information, appreciate the healthcare consequences of the situation, reason about treatment choices

TZD example and MOA

Pioglitazone (Actos) Insulin sensitizer (compliments metformin)

What is the purpose of NP certification?

Provides a process for validation of an advanced practice nurse's qualifications and knowledge for practice as a nurse practitioner

Why evaluate uterine size?

Provides information during the antepartum period about fetal growth and maternal well-being

4 month old developmental milestones "4, 4"

Reaches 4 an object or another toy Smiles 4 fun - spontaneously, no trigger needed Rolls from tummy to back Likes to play Vegins to babble Cries in different ways to show hunger, pain, tiredness Responds to affection Reaches for toy with one hand Uses hands and eyes together Follows moving things Watches faces Recognizes familiar people and things at a distance Holds head steady, unsupported Pushes down on legs when feet are on a hard surface May be able to roll over from tummy to back Brings hands to mouth Pushes up to elbows when lying on stomach

Consequences of long-term PPI use

Rebound hypersecretion when used >2 months Potential decrease in the absorption of Fe and B12 Increased risk of fractures, particularly in postmenopauseal women Decreased Mg absorption, increased risk of magnesium deficiency with loop diuretics Continue tapering medication with reducing dose, followed by every other day use, start BID ranitidine

Lifestyle modifications for HA prevention

Recognize and avoid triggers (chocolate, ETOH, certain cheeses, MSG, artificial sweeteners, perfume, stress, too much or too little sleep, altered routine, hunger, etc) Encourage regular exercise Attend to posture at workstation Use tinted lens to minimize glare and bright lights

Management of a pregnant woman who tests + for syphilis who has PCN allergy

Should be admitted for PCN desensitization PCN given as tx

L5 medications

Significant and contraindicated use Radioactive isotopes Cocaine

Causes of leukocytosis (WBC >10,000)

Significant bacterial infection Appendicitis Pyelonephritis Bacterial pneumonia Stress Pain Environmental extremes

S/s of active TB

Significant cough lasting >3 weeks Chest pain Hemoptysis or sputum production Weakness/fatigue Weight loss Lack of appetite Fever Chills Night sweats

Why should TCAS like Amitriptyline (Elavil) be avoided in the older adult (Beer's criteria)?

Significant risk of orthostatic hypotension

S/s of erosive gastritis

Stress NSAID use Nausea Burning pain limited to upper abdomen Worse with eating Tender at epigastrium, LUQ, slightly hyperactive BS

Effects of target organ damage from HTN on the brain

Stroke Multi-infarct dementia

Babinski reflex

Stroking the sole of the foot elicits fanning of the toes. No longer seen by 6 months.

AEs of statins

T2DM risk slightly increased with higher potency use. Benefit > risk. Caution with concomitant use of grapefruit juice with simvastatin, atorvastatin, lovastatin. Rhabdomyolysis Myositis

TB vs. PNA on CXR

TB = high in lungs (upper lobe) PNA = low in lungs (lower lobe)

Treatment of genital warts in the pregnant woman

TCA topical Cryotherapy C-section if warts obstruct canal

Abx that should not be given to individual on ACE/ARB because of risk for hyperkalemia

TMP-SMX

Single most reliable test to diagnose hypo and hyperthyroidism

TSH Highly sensitive and specific Only test needed to screen NL = 0.4-4.0

When would an individual with a thyroid nodule have a fine-needle aspiration biopsy?

TSH not suppressed (metabolically inactive) TSH suppressed but nodule not "hot"

When would an individual with a thyroid nodule have radioiodine ablation or surgery?

TSH suppressed and nuclear medicine thyroid scan reveals "hot" nodule

Validity

The results indicate what the researcher thinks they indicate Can be internal and external

Autonomy

The right of the competent person to choose a personal plan of life and action by exercising the right of self-determination, independence, and freedom

Pathogen associated with syphilis

Treponema pallidum (spirochete bacterium)

With or at risk for STI, test for...

Trich GC/chlamydia HIV Syphilis HAV HBV HCV HSV-2

What class of antidepressent is likely to cause cardiac dysrhythmia and seizures when intentionally overdosed?

Tricyclic (e.g. nortriptyline)

Medications with significant systemic anticholinergic effect

Tricyclic antidepressants (amitriptyline/Elavil, doxepin, oxybutynin, diphenhydramine, antipsychotics)

True or fales: The risk of torsades de points with erythromycin or clarithromycin is females > males

True

Etiology of acute gout

Uric acid over production (10%) Urate underexcretion (90%) including... Renal insufficiency Alcohol abuse Loop or thiazide diuretics Aspirin Purine-rich foods Organ meats Sardines Anchovies Spinach Oatmeal

Cervical cancer screening recommendations for women with hysterectomy with cervical removal

Can stop unless the surgery was done as treatment for cervical cancer or pre cancer (CIN2 or CIN3)

DDx for vulvovaginitis

Candida vulvovaginitis Bacterial vaginosis Genitourinary syndrome of menopause

Common adverse effects of SGLT2

Candidiasis UTI Dehydration Fractures

Aphthous stomatitis

Canker sore

CRAFFT questions

Car - have you ever driven in a car with someone who has been high or intoxicated Relax - do you ever use alcohol or drugs to relax? Alone - do you ever use alcohol or drugs while you are by yourself? Forget - Do you ever forget things you did while using alcohol? Friends - Do your family or friends ever tell you that you should cut down on your drinking or drug use? Trouble - Have you ever gotten into trouble while you were using alcohol or drugs? Screening for adolescent substance abuse

Nonpurulent skin conditions

Cellulitis Erysipelas Impetigo

What visual change do you expect the patient to report with a diagnosis of macular degeneration?

Central vision loss

Causes of transmission of Hep C

Contact with blood of an infected person, primarily through contaminated needles Less commonly through sexual contact with an infected person, birth to an infected mother, needlestick injury

Cervical cancer screening recommendations for women with a hx of CIN2 or CIN3

Continue screening for at least 20 years following when abnormality was found More frequent screening recommended for first few years after treatment to ensure all cancer cells removed

ART for HIV in pregnancy

Continue throughout pregnancy

Emancipating conditions in which the adolescent does not need parental consent (14-18y)

Contraception Prenatal care Evaluation and treatment for STIs Substance abuse

Antimicrobial pathogens in COPD exacerbation in the outpatient setting

Contribute to 30-50% of exacerbations Gram negs (H. flu, H. parainfluenzae, Moraxella catarrhalis) Gram pos (Streo, obeyni(

Emergency contraception options

Copper IUD up to 5-6 days later (0.09% effective) Ulipristal acetate as a single dose 30 mg (ella) up to 5 days Levonorgestrel in 1-2 doses (Plan B) should be taken within 72 hours

Slit lamp findings with angle-closure glaucoma

Corneal edema Bulging optic disc Irregular pupil shape Segmental iris atrophy Cornea and scleral injection Ciliary flush present

Sequalae associated with Kawasaki disease

Coronary artery dilation and coronary aneurysm

Major anticipated change in the lipid profile from PCSK9

Decrease LDL-C

Major anticipated change in the lipid profile from statin use

Decrease LDL-C

Major anticipated change in the lipid profile from fish oil supplementation

Decrease TG

Major anticipated change in the lipid profile from fibrate use

Decrease TG, increase HDL

Major anticipated change in the lipid profile from niacin use

Decrease TG, increase HDL

Risks to the mother from maternal prepregnancy obesity or excessive maternal weight gain

Decreased accuracy of fetal surveillance GDM HTN Increased risk of c-section Postpartum complications Longer hospital stay Anesthesia related problems

Beta-adrenergic antagonists (Beta blockers) MOA

Decreases HR, Decreases SV Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. When you take beta blockers, your heart beats more slowly and with less force, thereby reducing blood pressure.

ARB MOA

Decreases PVR Block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on the muscles surrounding blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced.

ACE-I MOA

Decreases PVR Produce vasodilation by inhibiting the formation of angiotensin II. This vasoconstrictor is formed by the proteolytic action of renin (released by the kidneys) acting on circulating angiotensinogen to form angiotensin I. Angiotensin I is then converted to angiotensin II by angiotensin converting enzyme.

Thiazide diuretic MOA

Decreases peripheral vascular resistance Na+, K+ Mg++ depleting Calcium sparing

You see a woman with hypothyroidism who is being treated with 100 mcg levothyroxine. TSH is 0.3. You recommend...

Decreasing dose to 88 mcg and re-evaluating in 2 months.

What is expected on the fundoscopic exam in the person with angle-closure glaucoma?

Deeply cupped optic disc

DDx for derm condition in a patient with constitutional signs and symptoms

Dermatologic manifestation of systemic disease Varicella Transepidermal necrosis Lyme disease SLE

Management of children and adolescents with high LDL-C and high risk for CVD/low HDL

Dietary counseling Increased physical activity

Nondihydropyridine CCBs examples

Diltiazem (Cardizem)

Adverse effects of fibrate

Dyspepsia Gallstones Myopathy Rhabdomyolysis if taken with statin Do not take with hepatic or renal disease

Initial s/s of HF

Dyspnea Fatigue Edema

Low CO sxms

Dyspnea Fatigue Edema Syncope

Symptoms of ACS in the elder (>75)

Dyspnea Neurological sxms: Syncope, weakness, acute confusion Chest pain or pressure in <50%

S/s of trichomoniasis

Dysuria Itching Vulvovaginal irritation Yellow-green vaginal discharge, occasionally frothy Cervical petechial hemorrhages Often without symptoms -- men almost never with symptoms

Efficacy of TZD

High, lowers A1c by 1-2%

Cost of DPP-4 inhibitors

High, ~$150/month

What flu vaccine is most appropriate for an elder >65 with no allergies?

High-dose trivalent IIV or quadrivalent IIV

How long does it take for estrogen replacement therapy to reduce vasomotor symptoms?

Higher doses provide relief in 4 weeks; lower doses take 8-12 weeks

Hypochromic

MCGC <31

Normochromic

MCHC 31-37

Microcytic

MCV < 80

Macrocytic

MCV > 96

Metzner's index

MCV/RBC. Helps to differentiate IDA from beta-thalassemia. Beta-thalassemia if <13 IDA if > 13

Dialysis encephalopathy

aka Dialysis Dementia; due to aluminum in dialysis solution

Polydactyly

extra fingers or toes

Treatment for psoriasis vulgaris

medium potency topical corticosteroid

anisocytosis

presence of red blood cells of unequal size

Finkelstein's test

stretching or lengthening of the thumb tendon to assess the possibility of de Quervain's disease, or tenosynovitis of the thumb tendon

Functional incontinence

the person has bladder control but cannot use the toilet in time Often occurs in the presence of mobility problems

Classification of mild acne

<20 comedones or <15 inflammatory lesions or <30 total lesions

NL for TC

<200

With anemia of chronic disease, Hct is rarely less than...

<28%

A1c goal in older adults who are frail or who have limited life expectancy

<8%

Stage 2 HTN

>140/>90

Who is at highest risk for COPD exacerbation and death

>2 exacerbations in the last year FEV1 <50% of predicted value and/or hospitalization

Microscopic exam findings in BV

>20 clue cells/HPF (vaginal epithelial cells with adherent bacteria) Few or no WBCs

Diagnostic criteria for generalized anxiety disorder

>3 of the following reported as occuring on most days for >6 months: WATCHERS Worry (Disproportionate to daily concerns, continued worry even when concerning event resolved) Anxiety (Mental and physical hypervigilance) Tension in body (Muscular tension, GI upset, others) Concentration difficulty (Reports of mind racing) Hyperarousal (Irritability common) Energy loss (Fatigue) Restlessness (feeling "keyed up") Sleep disturbance (difficulty initiating sleep)

Post term

>42 weeks

Tanner stage 5

Full adult

Classification of severe acne

>5 cysts, or total comedone count >100

Syndactyly

Fusing of digits Refer to pediatric hand/foot specialist

Organisms associated with BV

G. vaginalis M. hominis (anerobes)

Why is it improtant to test for and treat GAS?

GAS associated with rheumatic fever

Prenatal care 35-37 weeks

GBS culture (rectal and vaginal) Treat intrapartum if +

Microscopic exam findings in trichomoniasis

Motile organisms and large number of WBCs

DDx for macrocytic normochromic anemia with elevated RDW

"ABCDEF" Alcohol abuse B12 deficiency (including pernicious anemia, #1 cause) Compensatory reticulocytosis from blood loss and hemolysis Drugs/Dysplastic bone marrow disorders Endocrine (hypothyroidism) Folate deficiency/Fetus (pregnancy) Cells are abnormally large because of altered RNA:DNA ratio Next step test: vitamin B12 and folate

Peripheral artery disease

"Angina of the leg" Leg pain and numbness during activities (intermittent claudication) associated with systemic atherosclerosis that limits blood flow. May result in persistent infections or sores on the leg and feet, pale color to skin, some patients may be asymptomatic.

Diseases caused by S. pneumoniae and H. influenzae - "COMPS"

"COMPS" Conjunctivitis Otitis media Meningitis Pneumonia Sinusitis

Reactive Arthritis [Reiter's syndrome]

"Can't see, can't pee, can't climb a tree" Reactive arthritis usually targets your knees and the joints of your ankles and feet. Inflammation also can affect your eyes, skin and urethra. Previously, reactive arthritis was sometimes called Reiter's syndrome, which was characterized by eye, urethra and joint inflammation. Reactive arthritis isn't common.

Delirium etiology

"DELIRIUMS" DRUGS (Problems with TCA, antihistamine, antipsychotics) EMOTIONAL/ELECTROLYTE DISTURBANCE ( Low Na Low PO2/lack of drugs - CAP/COPD/MI, drug withdrawal) INFECTION (UTI, CAP) RETENTION/REDUCED SENSORY INPUT (Urinary or fecal retention) ICTAL or POSTICTAL STATE (Alcohol withdrawal common reason for isolated seizure) UNDERNUTRITION (Protein/calorie malnutrition, vitamin B12 or folate deficiency, dehydration) METABOLIC/MYOCARDIAL PROBLEMS (DM, hypo/hyperthyroidism) SUBDURAL HEMATOMA (Result of minor head trauma, due to a combination of brain atrophy and fragile blood vessels)

S/s of acute bronchiolitis

"Disease of the happy breather" Mildly ill child 3 months - 3years (most common <1 y) Viral etiology, usually RSV Wheezing in lower airway obstruction and crackles

Sxms of antidepressant discontinuation syndrome

"FINISH" Flu like symptoms Insomnia Nausea Imbalance Sensory disturbance Hyperarousal/HA Typically lasts <7 days Avoid with med taper over 6 weeks Not dangerous, but bothersome

S/s of peritonsillar abscess

"Hot potato voice" Difficulty swallowing Trismus Contralateral uvula deviation

DDx for microcytic hypochromic anemia with elevated RDW

"LIT" Lead toxicity IDA Thalassemia Decreased: Hgb, hct, RBC, MCV, MCHC Increased: RDW Small cell due to insufficient hemoglobin with new cells smaller than old cells Next step: Test ferritin for estimate of iron stores

Most likely WBC response in severe bacterial infection

"Left shift" Leukocytosis with neutrophilia and bandemia TWBC > 10,000

S/s of hyperparathyroidism

"Moans, groans, stones, and bones with psychic overtones." Loss of energy Poor concentration/memory Depression Osteoporosis/osteopenia INsomnia GERD Decreased libido Hair loss Bone and joint aches Kidney stones HTN Arrhythmias AFib Liver dysfunction Abnormal blood protein levels

Ddx for normocytic normochromic anemia

"Mr. B Calm" Marrow failure Renal failure (CKD) — reduction in epo Blood loss (acute) Chronic disease (most common) Aplastic anemia Leukemia Metastasis (other cancer) Decreased: Hgb, hct, RBC NL: MCV, MCHC, RDW Cells are made under normal conditions with sufficient hemoglobin

Headache red flags

"SNOOP" Systemic symptoms/secondary headache risk factors (HIV, malignancy, pregnancy, anticoagulation, elevated HTN) Neurologic signs (confusion, impaired LOC, nuchal rigidity, papilledema, CN dysfunction, abnormal motor function) Onset (sudden, abrupt, "thunderclap" suggest subarachnoid hemorrhage, with exertion, coughing, sneezing suggests increased ICP) Older than 50 or younger than 5 Previous HA history is reassuring. More worrying is first headache report in adult >30.

Precontemplation stage of change

#1 in the transtheoretical model of change. The patient is not interested in change and might not be aware that the problem exists/minimizes the problem's impact. The healthcare provider should help the patient to move toward thinking about changing the unhealthy behavior.

Contemplation stage of change

#2 in the transtheoretical model of change. The patient is considering change and looking at its positive and negative aspects. At the same time, the person reports feeling "stuck" with the problem. The healthcare provider should help the patient to examine benefits and barriers to change.

Preparation stage of change

#3 in the transtheoretical model of change. The patient exhibits some change behaviors or thoughts and often reports feeling that he or she does not have the tools to proceed. The healthcare provider should assist the patient in finding and using tools to help with change, continuing to work to lower barriers to change.

Action stage of change

#4 in the transtheoretical model of change. The patient is ready to go forth with change, often takes concrete steps to change, but is inconsistent with carrying through. The healthcare provider should work with the patient on use of tools, encouraging the healthy behavior change, praising the positive, acknowledging reverting back to former behavior as a common but not insurmountable problem.

Maintenance/relapse stage of change

#5 in the transtheoretical model of change. The patient learns to continue the change and has adopted and embraced the healthy habit. At the same time, relapse can occur and the person learns to deal with backsliding. The healthcare provider should give positive reinforcement for the behavior change.

Markers of acute HAV infection

+ HAV IgM Elevated hepatic enzymes > 10 x UL

Markers of past Hep B infection

+ HBsAb (Anti-HBs) "B = bye" Normalized hepatic enzymes

Management of the pregnant woman + for gonorrhea or chlamydia

+GC Ceftriaxone 240 mg IM + azithro 1 g PO if CT alone, azithromycin 1 g PO Test of cure in 3-4 weeks Rescreen in 3 months for new infection acquisition

Markers of acute Hep D infection

+HBsAG + Hep D IgM Markedly elevated hepatic enzymes

How should you change synthroid dosing in the pregnant woman?

30% increase as soon as pregnancy is confirmed Maternal euthyroidism is important for normal fetal cognitive development

Lymphocytes in CBC with diff

30% of differential in health Act on viruses When cell line activated = lymphocytosis

Classification of osteopenia

T score -1.0 to -2.5 BMD is between 1.0 and 2.5 SD below that of a young normal adult

Drugs for medium intensity statin therapy

Atorvastatin 10-20 Rosuvastatin 5-10 Simvastatin 20-40 Pravastatin 40-80 Lovastatin 40

Drugs for high intensity statin therapy

Atorvastatin 40-80 Rosuvastatin 20-40

SGLT2 inhibitor example and MOA

-Gliflozin (ex. canagliflozin, Invokana) Causes glucose excretion post glucose rise via kidney

Management of candida vulvovaginitis

-azole antifungal Oral: fluconazole (diflucan) or vaginal: miconazole (monistat), terconazole (terazol)

Normal limits for ESR

0-22

Frequency of prenatal visits

0-28 weeks: q4w 28-36 weeks: q2w >36 weeks: qweek

NL for AST/ALT

0-40

Postpartum psychosis

0.2% incidence Early onset usually by day 3 postpartum Characterized by delusions, hallucinations, agitation, insomnia, confusion Risk of infanticide, usually secondary to delusion about baby Maternal suicide risk is also increased

The child should remain in "time out" for what period of time?

1 minute for each year of life

Basophil in CBC with diff

1% of differential in health Increased in anaphylaxis When cell line elevated = Basophilia

Calcium requirements in pregnancy

1,000-1,500 mg elemental calcium per day, ~40% increase from baseline

Half life of caffeine

1.5-9

Length of treatment for AOM <2 y vs. 2-6y. vs. > 6 years

10 days 7 days 5-7 days

Newborns often lose up to what percentage of birth weight in the first week of life?

10%

When would chorionic villus sampling be performed? Amniocentesis?

10-12 weeks 15-20 weeks

When can you first auscultate FHT via abdominal doppler?

10-12 weeks Should be able to auscultate by 12 weeks

When do the lower lateral incisors erupt? Upper lateral incisors?

10-16 months; 9-13 months

At what point does the uterus rise above the symphysis pubis?

12 weeks

Stage 1 HTN

130-139/80-89

When do the lower first molars erupt? Upper first molars

14-18 months; 13-19 months

Recommended weight gain for overweight women during pregnancy

15-25

Incubation period for Hep A

15-50 days

Risk of clarithromycin/erythromycin + simvastatin/atorvastatin

15x increase of statin Risk for rhabdo

2 hour post prandial glucose target

160-180 mg/dL

When do the lower canine/cuspids erupt? Upper canine/cuspids?

17-23 months; 16-22 months

When do women first appreciate fetal movement?

18-20 weeks

Recommended amount of omega-3 intake

1g of EPA+DHA per day from oily fish (ex. 4oz salmon)

Medications to avoid int he older adult

1st gen antihistamines Medications for OAB TCAs Some SSRIs

Treatment of cough associated with viral URI

1st line: Antihistamine/decongestant (non-sedating antihistamine not helpful) 2nd line: Codeine, dextromethorphan

Asthma controller medications

1st line: ICS (preferred for persistent asthma, less than 20% absorbed systemically. Requires daily use) 2nd line: Inhaled corticosteroid/LABA (should not be used in patients whose asthma is well-controlled with an ICS alone. Requires daily use) 3rd line: Leukotriene modifiers (montelukast, additional benefit with allergic rhinitis, most often used in conjunction with ICS. 50% as potent as ICS inflammation control) 4th line: Inhaled muscarinic antagonists 5th line: Theophylline

Treatment of postinfectious cough that has persisted 3-8 weeks following sxms of infections

1st line: Ipratropium bromide (Atrovent HFA, SAMA) 2nd line: ICS x 1 week (salmeterol) 3rd line: 30-40 mg prednisone x 5 days

Ashtma reliever medications for acute bronchospasm

1st line: SABA (albuterol, piruterol, levalbuterol) Beta-2 agoonists activate beta2 receptors in airways going to the lungs 2nd line: SABA + systemic corticosteriods for aggressive treatment of inflammation during asthma flare (prednisone 40 PO X 5 days)

Until what age should you adjust for preterm gestation with developmental assessment?

24 months

The baby should be back up to birth weight by what time?

2 weeks

In females, time from tanner stage 2 to menarche? Time from tanner stage 2 to full adult height?

2 years; 3 years

DSM criteria for substance use disorder

2+ of the following in the past 12 months: Substance use in increasing amounts Desire to cut down Excessive time spent obtaining, using Craving to use Inability to maintain major role obligations Continued substance use despite recurrent social or interpersonal issues Using in hazardous positions Important activities given up due to substance use Tolerance Withdrawal

The typical INR goal during warfarin therapy for a 65 year old woman with afib is...

2-3

Dermatologic manifestations of varicella

2-3 mm vesicles that start on trunk then appear on limbs 2-3 days later Nonclustered lesions at a variety of stages, including crusts, with reasonably high rates of complication, including bacterial suprainfection

Embryo

2-8 weeks of pregnancy Implantation at 2 weeks

Max citalopram dose in adults >60

20 mg

By 18, what percentage of adolescents have used a prescription drug for a nonmedical purpose?

20%

Classification of moderate acne

20-100 comedones

Likelihood of symptomatic acute infection with acute HepA

20-30% of newly infected persons develop symptoms of acute disease - 15-25% clear the virus Acute illness is uncommon. Those who do develop acute illness recover with no lasting liver damage.

When do the lower second molars erupt? Upper second molars?

23-31 months; 25-33 months

S/s of cholecystitis

24h hx of significant epigastric and RUQ abdominal pain that is constant with 2-3 minute periods of increased pain Nausea/vomiting Fever Tenderness at epigastrum and abdominal RUQ + Murphy's sign Moderately elevated AST, ALT, ALP

Recommended weight gain for normal weight women during pregnancy

25-35

Recommended weight gain for underweight women during pregnancy

28-40

Reliever therapy for AR

2nd gen oral antihistamines Intranasal antihistamine/ocular antihistamine

S/s of duodenal ulcer

3 month history of intermittent upper abdominal pain Worse when stomach empty Better with food in stomach Epigastric, burning, gnawing pain about 2-3 h after eating Relief with food, antacids Awakening at 1-2AM with sxms (when stomach is most acidic) Tender at epigastrium Slightly hyperactive BS

Eosinophil in CBC with diff

3% of differential in health Act on allergens and parasites When cell

S/s of fifth's disease

3-4 days of mild flu-like illness, followed by 7-10 days of red rash that begins on face with "slapped-cheek" appearance, spreads to trunk and extremities Rash onset corresponds with disease immunity with patient viremic and contagious prior to but not after onset of rash

How many drug free half lives before the drug leaves the body?

3-5

Additional kcal requirements during pregnancy

300 kcal/d over baseline Caloric requirements are greater in women who conceive within 1-2 years of menarche and with multiple gestation

Early term

37-38 weeks +6 days Lungs fully developed, can make transition to extrauterine life These are sleepy babies! Need to be woken to be fed

Full-term

39 - 40w6d

When would a neonate present with chlamydial PNA?

3rd week of life

At what grade murmur can you palpate a murmur?

4

In males, time from tanner stage 2 to full adult height?

4 years

By 18, what percentage of adolescents have tried a cigarette?

40%

Treatment of depression in dementia

40% will have concomitant depression Standard tx with SSRI or SNRI keeping in mind DDIs

Average age of perimenopause

40-45

How much vitamin D should the young child take per day?

400 IU in exclusively breastfed infants

Late term

41w-41w6d

If a confidence level is 95%, what is the confidence interval?

5%

At what age would a neonate present with chlamydial conjunctivitis?

5-14 days post-birth

Immunization against herpes zoster is recommended by the CDC for all adults > what age?

50 for Shingrix or 60 for Zostavax

By 18, what percentage of adolescents have tried MJ?

50%

Insulin dosing for T1DM

50% basal, 50% bolus with insulin pump or rapid acting

Additional kcal requirements during lactation

500 kcal/d over baseline

The newborn should make at least _____ wet diapers per day

6 If less, concerned not getting enough breastmilk

What strains of HPV cause genital warts

6 and 11

When does separation anxiety begin?

6 months

At what age can the infant usually turn tummy-to-back, back-to-tummy without assistance?

6 mos

Monocytes in CBC with diff

6% of differential in health Act on debris When cell line activated = monocytosis

When do the lower central incisors erupt? Upper central incisors?

6-10 months; 8-12 months

How long do acne therapies take (at minimum) to take effect?

6-8 weeks Lesion on the face today started 2 months ago

How long does antimicrobial treatment for active TB infection last?

6-9 months

NL for TG

<150

BP goal age > 60 with no DM or CKD

<150/90

When can you terminate HPV/cervical canceer screening in women with consecutive negative cytology results?

65

After a single coital act, women who do not use contraception have what % chance of becoming pregnant?

7.2%

By 18, what percentage of adolescents have tried alcohol?

70%

You initiate a patient on levothyroxine. When should you recheck the TSH to ensure adequate therapy.

8 weeks

Fetus

8 weeks to term

Newborn visual range

8-12 in

GFR (glomerular filtration rate)

90-120 mL/min Renal function in normal young adult

How do you manage a patient who shows up with grade 3/grade 4 retinopathy?

911 to ED Likely also has encephalopathy and is acutely confused

NL for LDL

<100

Recommended weight gain for obese women during pregnancy

<11-20

BP goal age <60 with no DM or CKD

<140/90

Diagnostic criteria for major depressive episode

>5 symptoms present in the same 2 week period: SIGECAPS Sleep (insomnia or hypersomnia) Interest (depressed mood, loss of interest or pleasure, irritability) Guilt (feelings of worthlessness) Energy (fatigue) Concentration (Diminished ability to think clearly) Appetite (increase or decrease, loss of food enjoyment) Psychomotor (Retardation or agitation) Suicide (Recurrent thoughts of death, passive without plan most common)

HDL cholesterol normal limits

>60

Treatment of viral bronchitis

>75% self limiting, resolve in 2 weeks For protracted, problematic cough, consider: Short course of oral corticosteroid (prednisone 40 mg PO daily for 3-5 days) SAMA (like ipratropium bromide) SABA (albuterol)

FEV1 in well controlled vs. not well controlled vs. very poorly controlled asthma

>80% 60-80% <60% predicted/personal best

Pathogen associated with malignant otitis externa in person with DM, HIV/AIDS, chemo, other immunocompromise

>95% psuedomonas spp.

CPT code

A 5 digit numerical code that describes all services to be reimbursed E&M Surgery and and anesthesia Lab, radiology, pathology

Club foot

A birth defect in which the foot is twisted out of shape or position. Treated with serial casting

Acute bronchitis

A clinical diagnosis characterized by lower airway inflammation, usually presenting with cough with/without sputum production lasting >5days, typically following URI Noted only in the ABSENCE of asthma, COPD, or other airway disease

Case management

A collaborative processes of assessment, planning, facilitation, and advocacy for options and services to meet an individuals healthcare needs

Asthma

A common chronic disorder that is complex and characterizd by underlying airway inflammation that leads to variable airflow obstruction and bronchial hyperresponsiveness Airway inflammation first -- bronchospasm follows

COPD

A common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitations that is not fully reversible

Managed care

A healthcare system that integrates the financing and delivery of healthcare services to covered individuals, most often by arrangements with selected providers

Nurse Practice Act

A law that is enforced by each state's nursing board Nurses at all levels must comply with the law and related rules in order to maintain their licenses

Substrate definition (drug therapy)

A medication or substrate that is metabolized by the isoenzyme, utilizing the enzyme in order to be modified so it can reach drug site of action and/or be eliminated About 50% of all prescription medications are CYP450 3A4 substrates (ex. Sildenafil/viagra, atorvastatin, simvastatin, venlafaxine, alprazolam

Varicocele

A palpable "nest of worms" scrotal mass that is only evident in standing position

Dementia

A slowly developing impairment of intellectual or cognitive function that is progressive and interferes with normal functioning

Delirium

A sudden state of rapid changes in brain function reflected in confusion, changes in cognition, activity, and level of consciousness Precipitated by an acute underlying cause like acute illness, surgery, etc

Power analysis

A power analysis is a mathematical calculation used to determine the minimum sample size needed to reasonably detect a given effect Determines on determination of statistical significance, a priori sample size, effect size A power of 80% is general standard

Syncope

A transient loss of consciousness characterized by a loss of postural tone, typically sudden in onset, with no warning, with spontaneous recovery Since the patient has no warning of the event, the patient often has injury as a result of the fall

Gram - abx

Aminoglycosides

Dihydropyridine Calcium channel blockers examples

Amlodipine, nifedipine

S/s of communicating hydrocele

Amount of fluid in scrotum varies with position: larger with dependent upright position (day) and smaller after lying flat (upon awakening)

Targets for glycemic control in diabetics

A1c <7% - more or less stringent considered by individual FPG 80-130 Peak postprandial (1-2h post meal) <180

Diagnosis of PAD

ABI <0.9 Doppler US or MRI to assess blood flow Treadmill test to assess severity Arteriogram to identify blocked arteries

Antihypertensive drug choice for CKD present with or without diabetes

ACE or ARB

Antihypertensive treatment choices for stroke prevention

ACE, diuretic

Antihypertensive treatment choices for CKD

ACE/ARB

Antihypertensive treatment choices for DM

ACE/ARB CCB Diuretic

Antihypertensive treatment choices for post-MI/Clinical CAD

ACE/ARB + BB

Antihypertensive treatment choices for HF

ACE/ARB + BB + diuretic + spironolactone

Antihypertensive treatment choices for CAD

ACEI Diuretic BB CCB

What should be considered with any acute illness in the elder?

ACS, UTI

Medicare C coverage

AKA Medicare Advantage Offered by private companies that are approved by medicare Provide PPO or HMO services Includes part A, part B and prescription drug coverage

Neutrophils in CBC with diff

AKA poly or segs Bands = young neutrophils 60% of differential in health Act on bacteria When cell line activated = neutrophilia

In an older adult on ACEI with mild renal impairment, when should the adult take the medicine to avoid hyperkalemia?

AM dose

Antimicrobials for UTI in febrile infants and children 2-24 months

Amox 20-40 mg/kg/d in 3 divided doses x 7-14 days Bactrim 6-12 TMP/30-60 SMX per kg/day in 2 doses x 7-14 days Cephalosporin x 7-14 days

What drug should you avoid using in mono?

Amoxicillin Will have 95% likelihood of breaking out with flat pink rash - autoimmune rash

First line antibiotic for acute OM in children

Amoxicillin 80-90 mg/kg/d in 2 divided doses or augmentin With PCN allergy: cefdinir, cefuroxime, cefpoxime, ceftriaxone

Second line treatment for ABR

Amoxicillin-clavulanate 2000 mg/125 mg P.O. BID or doxycycline 100 mg P.O. BID or 200 mg PO daily

First line treatment for ABR

Amoxicillin-clavulante 500 mg/125 mg P.O. TID or 875 mg/125 mg P.O. BID

What labs should be checked periodically with second generation antipsychotics?

At baseline: FHx, BMI, waist circumference, BP, blood sugar, lipid profile Weight at every visit BP, blood glucose, lipids at 3 months and then annually Lipids every 6 years

When should you perform spirometry or peak flow?

At every asthma-related visit This gives you an idea of the severity of the air trapping

When initiating pharmacologic treatment for osteoporosis in women, you should obtain repeat DEXA

At the end of therapy

Inducer definition (drug therapy)

Accelerates the activity of the isoenzyme so that substrate is pushed out the exit pathway, leading to a reduction in substrate level

Management of acute epiglottitis

Attention to airway maintenance Referral to ED Antimicrobial therapy Inpatient admission

Complementary therapy for AR

Acupuncture

Most common AEs associated with psychotropic medications

Anorgasmia Erectile dysfunction Altered libido Increased suicidality in children, adolescents, and young adults <24

Markers of past Hep C infection

Anti-HCV present HCV RNA absent Normalized hepatic enzymes

Management of peritonsillar abscess

Attention to airway maintenance Referral to appropriate care setting such as ED - ENT consult Antimicrobial therapy Impatient admission Surgical intervention (T&A)

When should you initiate insulin for T2DM?

At time of diagnosis when A1c at time of diagnosis >9% with symptoms Can use 2-3 course of insulin to help achieve normoglycemia When >2 agents are optimized to maintain glycemic control, fail When acutely ill

When should the infant go to the dentist?

At time of first tooth eruption or 1 year

Causes of anemia

Acute blood loss Chronic blood loss Reduced RBC production Premature RBC destruction

DDx of acute wheezing in children

Acute bronchiolitis Acute bronchitis Asthma

ABCDEFGs of T2DM treatment

ASA 75-162 mg/d (Plavix 75 in ASA allergy) Blood pressure control with T2DM and HTN, use >2 of: thiazide-type diuretic, ACE/ARB Cholesterol control with statin for age >40 or hx of ACS Creatinine, GFR, and microalbumin checked annually Diet: Limit trans and saturated fats, refer to dietitian for medical nutrition therapy Dental: Reinforce ongoing dental care Exercise: Should have 30 minutes aerobic x 5 per week and resistance 3x per week Eye exam annually Foot exam at every visit. Teach protective foot behavior, comprehensive lower extremity sensory exam annually Goals: Glycemic, lipid, physical activity

Labs elevated during cholecystitis

AST, ALT, ALP

S/s of IBS

Abdomincal Pain and discomfort at least 2-3 days in the last three months associated with 2 or more of the following: change in frequency of stool, change in formation of stool. Absence of rectal bleeding, fever, weight loss, elevated CRP/ESR

Characteristics of pathologic murmurs

Abnormal hx Higher grade (>4) Radiation beyond the precordium to neck, axilla, or other locations S1, S2 obliterated With thrill or heave PMI displaced Increases in intensity with supine to stand position change

S/s of cervical canceer

Abnormal vaginal bleeding Vaginal discomfort during intercourse Malodorous discharge Dysuria Typically asymptomatic

S/s of endometrial cancer

Abnormal vaginal bleeding postmenopausal Heavy, frequent menstrual periods or intermenstrual bleeding in pre- and peri-menopausal women

Uterine fundal height gain from 20-36 weeks gestation

About 1 cm gain in fundal height per week Usually concordant with gestational age + or - 1cm

What size is the uterus at 10 weeks?

About the size of a baseball

S/s of prepatellar bursitis

Abrupt onset of knee pain with focal tenderness and swelling Full ROM limited by pain

Treatment of acute HCV infection

Antivirals, supportive care

1st line treatment for otitis externa

Acetic acid with propylene glycol and hydrocortisone (VoSoL) Systemic antimicrobial seldom neded Ear canal cleansing is important

The reduction in free androgens noted in a woman taking combined oral contraception can yield an improvement in...

Acne vulgaris

What derm condition are you likely to find on sun exposed areas?

Actinic keratosis

Contraindication to IUD

Active infection

S/s of acute pancreatitis

Acute onset epigastric pain radiating to the back with nausea, bloating, and vomiting Epigastric tenderness, hypoactive BS, distended and hypertympanic abdomen + lipase, amylase

Treatment of chicken pox

Acyclovir within 24-48h Acetaminophen for fever Avoid aspirin (Reye's syndrome risk) and NSAID (necrotizing fascitis risk)

Treatment of herpes zoster

Acyclovir within 72h Analgesia Treat itch with ice pack, calamine lotion, avoid clothes rubbing on lesions

What age group should be screened for HCV regardless of HCV risk factors?

Adults born 1945-1965

Risk factors for antibiotic resistance

Age <2 or >65 Daycare exposure Prior antibiotics within the past month Prior hospitalization within past 5 days Comorbidities Immunocompromised

Who should not have high-intensity statin therapy?

Age > 80 Impaired renal function Frailty Multiple comorbidities With a fibrate

Women at increased risk of giving birth to baby with open neural tube defect or Down syndrome

Age >35 FHx of birth defects Previous pregnancy where baby had birth defect Maternal hx of type 1 DM

Risk factors for preeclampsia

Age >40 First pregnancy DM High BMI Antiphospholipid syndrome Primary HTN Renal disease FHx Multiple gestation African acnestry Vitamin D deficiency Periodontal disease

S/s of lumbar spinal stenosis

Age >50 Standing discomfort with improvement in symptoms with bending forward nearly universial Pseudoclaudication (leg pain that worsens with activity and improves with rest) Bilateral lower-extremity numbness, weakness in the majority

Who is eligible for Medicare?

Age >65 Age <65 with certain disabilities People of any age with ESRD requiring kidney transplant or dialysis

Risk factors for lactic acidosis on metformin

Age >80 GFR <45

Presbyopia

Age-related visual impairment from hardening of the lens Results in close vision results Nearly all >45 year olds need reading glasses as a result

Senile cataracts

Age-related visual impairment from lens clouding resulting in progressive vision dimming, distance vision problems Potentially correctable with surgery, lens implant

Risk factors for macular degeneration

Aging, tobacco use, sun exposure, family history

Drug of choice for preventing exercise induced bronchospasm

Albuterol Use 15-30 mintues prior to activity

Common causes of AMS "AEIOU-TIPS"

Alcohol Acidosis Endocrine Epilepsy Electrolytes Encephalopathy Infection Opiates Overdose Uremia Underdose of needed meds Trauma Insulin, too much/to little Poisoning Psychosis Pharmacology, especially mentation-alterating meds Stroke Seizure Syncope

Dementia etiology

Alzheimer type - 70-80% Vascular (multi-infarct) dementia - 20% Parkinson disease - 5% Miscellaneous causes (HIV, dialysis encephalopathy, neurosyphilis, normal-pressure hydrocepahlus, Pick's disease, Lewy body disease, frontotemporal dementia About 30% of people with Alzheimer-type dementia also have vascular dementia

Management of functional incontinence

Ameliorated by having assistant who is aware of voiding cute available to help with toileting activities

Screening recommendations for chronic Hep B infection

All pregnant women Persons born in regions with intermediate or high prevalence of HBV US born persons not vaccinated as infants whose parents were born in regions with high rates of Hep B Infants born to HBsAg positive mothers Household, needle-sharing, or sex partners with HBV+ persons MSM IVDU Elevated liver enzymes of unknown etiology Hemodialysis patients Persons needing immunosuppressive or cytotoxic therapy HIV+ Donors of blood, plasma, organs, tissues, or semen

Who should receive DEXA screening

All women >65 and men >70 Women or man >50 who has broken a bone Adults with a condition like RA or who are taking chronic corticosteroids or PPIs Adults >50 with physical inactivity, low calcium intake, alcohol abuse, CF, hyperprolactinemia, DM, adrenal insufficiency, celiac disease, IBD, multiple myeloma, leukemia, CNS disorders, thyroid hormone

DDx for microcytic hypochromic anemia with NL RDW

Alpha or beta thalassemia minor Through an inherited genetic variation, small pale cells Will need to order Hgb electrophoresis for evaluation of hemoglobin variants

Definition of COPD exacerbation

An event in the natural course of the disease characterized by the patient's baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in management

Management of lumbar-sacral strain

Analgesia PT Heat or ice as indicated by pain response Muscle relaxers can be helpful but all sedating (avoid SOMA)

Management of lumbar radiculopathy

Analgesia Physical conditioning and therapy Ice 4-6 weeks of conservative therapy with ice/heat/NSAIDs specialty evaluation/intervention indicated for rapidly evolving defect, persistent neurological defect without resolution

Management of postmenopausal women with low libido and hot flashes on estrogen replacement therapy

Androgen replacement

Consider upper endoscopy in the presence of "ALARMS" findings with GERD diagnoses:

Anemia (iron deficiency) Loss of weight (involuntary) Anorexia (persistent) Recent onset of progressive symptoms Melena or hematemesis Swallowing difficulty (dysphagia and odynophagia)

CCB AEs

Ankle edema (particularly with DHP use) - dose dependent Avoid or use with caution in the presence of HF, renal/hepatic impairment

When choosing pharmacologic intervention to prevent recurrence of duodenal ulcer, you prescribe:

Antimicrobial therapy

Antibiotics for mild-moderate COPD exacerbation and acute exacerbation of chronic bronchitis

Antimicrobial therapy not usually indicated If prescribed: amoxicillin, TMP-SMX, doxycycline (best choice), cephalosporin

Treatment of chronic HCV infection

Antivirals

Maternal factors contributing to IUGR

Any condition that can lead to decreased uterine and placental blood flow: Stress, HTN, smoking, cocaine, DM, CKD Any condition that leads to decreased O2 carrying capacity: Poorly controlled asthma or other pulmonary disease, smoking, profound anemia, HD Insufficient prenatal care Malnutrition with poor weight gain Chronic infection Placental abnormality including abruption, placenta previa

At risk population for herpes zoster

Anyone with a hx of varicella. Nearly all in US age >40 has had varicella. Most cases occur after 50.

Most common harsh murmur

Aortic stenosis

Alpha 1 antitrypsin deficiency

Approximately 3% of people with COPD have AATD Perform in all patients with a COPD diagnosis in areas with high prevalence COPD < age 45 European ancestry FHx Panniculitis

Best dressings for burns

Aquacel Duoderm Xeroform Mepitel Acticoat

The newborn baby should have ______ small bowel movements per day

Around 4+

When should you use PCSK9?

As adjunct to diet and other lipid-lowering drugs including statins for familial hypercholesterolemia or CVD when LDL with standard meds not met

The 5 A's of smoking cessation

Ask - Identify and document tobacco use status Advise - Urge every tobacco user to quit Assess - Is the tobacco user willing to make a quit attempt at this time Assist - Use counseling and pharmacotherapy to help the patient quit Arrange - Schedule follow up contact within the 1st week of the quit date

Effects of target organ damage from HTN on the cardiovascular system

Atherosclerosis MI LVH HF

External validity

Assessment of the inferences or causal relationship Design and process may be perfect, but the inference is not supported

Giant Cell Arteritis (Temporal Arteritis)

Autimmune vasculitis involving primarily cranial vessels. Cell-mediated immunity is the primary problem. The production of cytokines, in particular interleukin-6, are important drivers and correlate with severity. Characterized by headaches, visual symptoms, elevated ESR, and visible temporal artery

Etiology of giant cell arteritis

Autoimmune vasculitis that affects medium and large sized vessels as well as the temporal artery Inflammation and swelling of the arteries leads to decreased blood floow Disease most commonly occurs in individuals 50-85 (usually females)

IBD (inflammatory bowel disease)

Autoimmune-mediated intestinal ulceration, inflammation Can be detected microscopically and macroscopically Crohn's disease: mouth to anus UC: Colon only

Treatment of the older woman with recurrent UTI

Avoid chronic antimicrobial therapy Vaginal low dose estrogen cream (you replace estrogen - helps to recolonize with lactobacilli)

Beer's criteria and PPIs

Avoid scheduled use for >8 weeks unless high-risk patient

Sun safety information for infants < 6 mos

Avoid sun exposure Dress in lightweight long pants, long-sleeved shirts, and brimmed hats that shade the neck Minimal amount of sunscreen can be applied to small areas like face and back of hands If an infant gets sunburned, apply cold compresses to affected areas

Sun safety information for individuals > 6 months

Avoid sun exposure with shade and clothing Use sunscreen > 15 SPF that protects against UVA and UVB — apply ~ 1 oz. Use extra caution near water, sand, and snow, as these reflext UV rays and can result in sunburn more quickly

Pharmacologic treatment of lower risk CAP - remember "ABCDE)

Azithromycin Biaxin/clarithromycin Doxycycline Erythromycin 1st line - doxy

1st line therapy for chlamydia

Azithromycin 1 g PO as a one time dose

1st line treatment for penicillin-allergic strep pharyngitis?

Azithromycin x 5 days Clarithromycin x 10 days

Nonpharmacologic strategies to improve functional performance and reduce problem behaviors in dementia

Behavior modification Scheduled toileting Prompted voiding to reduce urinary incontinence

How do you treat a patient with B12 deficiency and reticulocytosis?

B12 injections AND B-complex vitamin with Fe because of the reticulocytosis

Codependence

Behavior patterns of family members and friends that are strongly affected by the person's substance use Making excuses Providing funds Strong sense of guilt because their efforts are not helpful in curing the substance abuser

Management of urge incontinence

Behaviroal therapy Antimuscarinics (tolterodine, oxybutynin, solifenacin succinate, darifenacin, fesoterodine fumarate) Mirabegron (myrbetriq) Botulinum toxin injections

What should you use OTC to treat itchy/inflamed immunization sites?

Benadryl cream

When to test for T2DM in children

BMI >85th percentile Weight-for-height >85th percentile Weight >120% of ideal for height + FHx or race/ethnicity or signs of insulin resistance or maternal history of DM or gestational DM At age 10 or at onset of puberty then every 3 years

Hypertensive emergency

BP > 180/130 with evidence of organ damage Tx: TO ED -- IV *Labetalol or Nicardipine* to ↓ MAP by 25% in 1st hour then normalize BP over next 8-24hrs CAUTION: Organ Ischemia w/ ↓ in MAP

S/s of preeclampsia

BP >140/90 or with existing primary HTN if >30/>15 Must be successive measurements 4-6 hours apart Proteinuria >300 mg/24 h or >1+ on 2 random urines no more than 6 hours aaprt Sudden increase in edema or onset of facial edema

Topical antimicrobials for burns

Bacitracin Mafenide acetate Mupirocin Silver sulfadiazine

Necrotising fasciitis

Bacterial flesh-eating disease

Empiric therapy for CAP for children

Bacterial: amox 90 mg/kg/d in 2 doses x7-14 d Atypical: Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg/d on days 2-5

Genital candida albicans in a man presents with the following:

Balanitis Groin fold involvement Scrotal excoritation

Onset of pathologic jaundice in the newborn

Before first 24h of life Etiology: biliary atresia

How often should you check hepatic enzymes during statin therapy?

Before initiating No recommendation to continue to check during use

When should the family initiate "time out?"

Begin introducing at 18 months Fully implemented by 24 months

SDRI effect on mood/best use

Best effect on improving mood when insufficient response with SSRI or as a solo agent Potentially activating Bupropion (Wellbutrin)

SSRI effect on mood/best use

Best effect on lifting and smoothing mood Most to least energizing: Fluoxetine (prozac), sertraline (zoloft), citalopram (celexa), escitalopram (lexapro), paroxetine (paxil) "Oil in the mood motor"

SNRI effect on mood/best use

Best effect on lifting and smoothing mood plus increasing focus Occasional reports of being energizing, helpful in anxious and/or resistant depression Venlafaxine (effexor), duloxetine (cymbalta), desvenlafaxine (pristiq)

Prophylactic medications for migraine

Beta blockers (metoprolol, propranolol) Tricyclic antidepressants (Amitriptyline, nortriptyline) Antiepileptic drugs (AEDs - divalproex sodium, sodium valproate, topiramate) Nutritional supplements (Butterbur, feverfew, coQ10, mag, riboflavin)

S/S of ectopic pregnancy

Bilat abdominal pain (one side may hurt more than the other) Adnexal tenderness Menstrual irregularitu Uterus size < gestational age Adnexal mass Lack of normal hCG increase <6,000 Low for GA serum quant hCG Transvaginal US fails to identify intrauterine gestational sac

Bile acid sequestrant MOA

Bind bile acids in GI > prevent reuptake of bile > liver uses cholesterol to make more bile > HMG CoA Reductase increased > Serum Cholesterol Levels Drop

Treatment of osteoporosis

Bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid) Calcitonin Estrogens/hormone replacement therapy Raloxifene Parathyroid hormone RANKL inhibitor Vitamin D >800-1,000 (more if deficient) 1,000-1,200 calcium

What is your #1 differential in an older adult presenting with painless, gross hematuria?

Bladder cancer

Potential serious complication of giant cell arteritis

Blindness

Bullous miringitis

Blister on TM during AOM

Inhibitor definition (drug therapy)

Blocks the activity of the isoenzyme, limiting substrate excretion, allowing increase in substrate levels, and possible risk of substrate-induced toxicity Erythromycin, clarithromycin are CYP450 3A4 inhibitors — can increase serum levels of simvastatin, atorvastatin, venlafaxine, alprazolam

Transmission of Hep D

Blood, body fluids Must have had hep B

Why are older adults at risk for subdural hematoma?

Brain atrophy with cranium growth creates more space for brain to move and receive trauma

Diagnostics to order in the older adult with new onset altered mental status as directed by patient risk factors and presentation

Brain imaging PET scan Tox screen CXR ESR HIV Additional studies as needed

Most prevalent cancer in women

Breast

Carotid bruit vs. radiating murmur

Bruit: Softer vs. murmur: louder Bruit: Unilateral vs. murmur: bilateral Bruit: different sound than found in chest vs. murmur: same sound and timing with chest

S/s of venous insufficiency

Burning Swelling Throbbing Cramping Aching Heaviness in legs Restless legs and leg fatigue Telangiectasias

Management of prepatellar bursitis

Bursal aspiration Avoiding activity Ice NSAIDs If no improvement after 4-8 weeks, intrabursal corticosteroid injection

What class of antihypertensive would you not use in HF?

CCB

Sepsis workup components

CBC with WBC diff (bacterial or vial shift) Blood culture UA and Culture/sensitivity LP for CSF analysis (if altered neuro exam, looking for pleocytosis) CXR (if altered resp exam) Stool culture if diarrhea present

Minimum diagnostic evaluation in CAP

CBC with WBC differential BUN/Cr CXR ** Anemia is a risk factor for more severe PNA** May also want to ask BMP (older adult will waste Na and conserve K)

Sequalae of acute Hep C infection

Chronic Hepatitis C Hepatocellular carcinoma Hepatic failure

What CN are you testing when you ask the patient to smell something?

CN I

What CN are you testing when you use a snellen chart?

CN II

What CN are you testing when you ask the patient to "follow my finger with your eyes?"

CN III, IV, VI

What CN are you testing when you ask the patient to swallow?

CN IX

What CN are you testing when you ask the patient to clench their teeth?

CN V

What CN are you testing when you ask the patient to puff out their cheeks?

CN VII

What CN are you testing with whisper testing?

CN VIII

What CN are you testing when you ask the patient to say "Aah"

CN X

What CN are you testing when you ask the patient to shrug?

CN XI

What CN are you testing when you ask the patient to stick out their tongue?

CN XII

Sensorineural hearing loss

CN XIII Inner ear or nerve is damaged from advanced age, ototoxic medications, immune dosorders or trauma Weber: Sound lateralizes to unaffected ear (buzzing sound either quieter or not heard in affected ear) Rhine: Air conduction > bone conduction Treat with hearing aids or cochlear implants with expert consultation

Rubeola/measles sequalae

CNS and respiratory tract complications Permanent neurologic impairment

Best birth control method for women <20

COC, patch, ring POP Implant (Injection and IUD are category 2)

COPD vs. asthma

COPD is not reversible; asthma is

Definitive diagnosis of giant cell arteritis

CRP, ESR elevated Needs superficial temporal artery biopsy Color duplex ultrasonography can be used as an alternative or complement to biopsy

The most helpful imaging study in the evaluation of appendicitis is

CT with contrast Can do abd u/s in think adults and children

Diagnostics for suspected ovarian cancer

CT with contrast of abdomen and pelvis, US, MRI Tumor markers (CA125) not speciic Fine-needle aspiration or percutaneous biopsy of mass not routinely recommended as may delay treatment

AEs of cholinesterase inhibitors

CV: Hypotension, Bradycardia GI: Abdominal Cramps, nausea, Diarrhea, Involuntary Defecation GU: Rupture if obstructed Lungs: Exacerbates asthma (bronchoconstriction) CV: Symptomatic Bradycardia, Dysrhythmias in hyperthyroid pts Eye: Retinal Detachment (Sustained contraction) Neuromuscular Blockade -from high accumulation; paralysis of respiratory muscles

Drug interactions with St. John's Wort

CYP450 3A4 inducer Concomitant use of St. John's Wort and 3A4 substrate can lead to reduced target drug levels and diminished therapeutic effect, possible treatment failure Medications of particular concern include select antiretrovirals, combined oral contraceptives, and cyclosporine Can lead to contraceptive failure Can increase HIV viral load

Thiazide diuretics and fractures

Calcium sparing Lower observed rate of fractures in women who are long-term thiazide diuretic users

Management of diverticulitis

Can be managed as an outpatient 3 day gut rest with clear liquids Outpatient therapy for mild diverticulitis must provide antimicrobial coverage for gram neg and anaerobes: Flagyl (Anaerobes) + TMP-SMX, cipro, or levofloxacin If severe send to ED

18 month old developmental milestones

Can name single word objects Says "no" like an 18 year old Acts like an 18 year old by copying work that adults do Stranger danger reemerges Says several single words Says no Knows what ordinary things are for Points Scribbles Walks Drinks from cup Eats with a spoon

3 year old developmental milestones

Can ride a tricycle - has figured out how to alternate feet Builds a 3 block tower with ease Speaks in 3 word sentences Can draw a circle Separates easily Takes turns in games Follows 3 steps Knows age, name, sex Intelligible speech Builds towers of 6 blocks Climbs' Runs Alternates feet

Management of acute bacterial prostatitis age <35

Ceftriaxone 250 mg IM as 1 time dose + doxycycline 100 mg PO BID x 10 days

Management of epididymoorchitis in men <35

Ceftriaxone 250 mg IM as a single dose + doxycycline 100 mg PO BID x 10 days Advise scrotal elevation to help with symptom relief

First line therapy for PID

Ceftriaxone 250 mg IM as a single dose + doxycycline 100 mg PO x 14 days + metronidazole 500 mg PO BID x 14 days

Management of gonoccoal urethritis and vaginitis

Ceftriaxone 250 mg IM as one time dose + azithromycin 1 g PO x 1 dose (cotreat for chlamydia)

What medications prevent micronutrient absorption leading to anemia?

Chronic PPI use (B12, iron) Metformin (B12)

S/s of primary syphilis

Chancre (painless) ~3 weeks duration Localized lymphadenopathy

Prochaska and DiClemente Stages of Change theory

Change occurs dynamically. Theory notes five stages of preparation and maintenance for change (trans theoretical model) 1. Pre-contemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance/relapse

When should you consider lipid-lowering medication for children and adolescents?

Children 8+ with LDL-C >190 (or >160 with a family hx of early heart disease or >2 additional risk factors, or >130 with diabetes)

Examples of bile acid resins/sequestrants

Cholestyramine, cholestipol, colesevelam

Sequalae of acute Hep B infection

Chronic Hep B Hepatocellular carcinoma Hepatic failure

Management of acute bacterial prostatitis, uncomplicated, men at low risk for STI

Ciprofloxacin 500 mg PO BID or ofloxacin 200 mg PO daily x 14 days

What antidepressant dose must you limit due to risk for QT prolongation

Citalopram (max dose 40 mg/d for all or 20 mg/d for adults >60)

What SSRIs have no anticholinergic effect?

Citalopram, escitalopram, sertraline

Asthma assessment

Classify asthma severity at initial visit and asthma control and follow up visits Identify precipitating and exacerbating factors, including comorbid conditions that aggravate asthma Identify patients high risk for exacerbations and death from asthma Regularly assess patient's family's knowledge and skills for self-management including medication device technique

What do you need to establish diagnosis of GERD?

Clinically with typical symptoms of heartburn and regurg Upper endoscopy, barium radiograph, H. pylori testing not routinely needed to make diagnosis

Hydrocele

Collection of serous fluid that causes painless scrotal swelling, easily recognized by transillumination

What pharmacologic therapy should you consider for females with moderate to severe acne?

Combined estrogen-progestin hormonal contraception Results in reduction in androgen levels, decreased sebum production After 3 months of continuous use/when skin is clear prior to significant acne improvement

Cause of infant non-communicating hydrocele

Common Sealing of abdominal cavity during gestation with residual trapped peritoneal fluid in scrotal sac

H. Influenzae

Common bacterial pathogen in ABRS, AOM, CAP, particularly with recurrent infection and tobacco use Gram - bacillus Causes 36% of ABRS in adults >30% are penicillin resistant because of production of beta-lactamase that cleaves beta-lactate ring in most penicillins. Most cephalosporins are stable in the presence of beta-lactamase.

Grade 2 Hypertensive retinopathy (low grade)

Common in longstanding, pooly-controlled HTN, reversible when HTN treated Narrowing of arterioles with severe local constriction No vision change or permanent findings

Grade 1 Hypertensive retinopathy (low grade)

Common in longstanding, pooly-controlled HTN, reversible when HTN treated Narrowing of arteriorlar branches No vision changes or permanent findings

Bactrim and older adults

Concern for drug-induced hyperkalemia Can lead to arrhythmias (tall, tented T-waves) Especially with cocommitant ACEIs or ARBs

Nurse credentialing

Confirms the healthcare provider meets practice authority regulations in the state where the practice/hospital is located Background check Provides practice authority in a given institution or healthcare setting Defines clinical, hospital privileges Enables insurance reimbursement

Most common presentation of ACS in the older adult

Confusion and rapid breathing Some dyspnea on exertion

Venous insufficiency (PVD)

Congenital absence of or damage to venous valves resulting in reflux through superficial veins Thrombus formation can also cause valve failure

Risks to the fetus from maternal prepregnancy obesity or excessive maternal weight gain

Congenital anomalies Macrosomia/LGA Risk for neonatal hypoglycemia Lower rate of successful breastfeeding Increased rates of preterm birth, neonatal and infant mortality Predisposition to insulin resistance

Who should not receive citalopram due to risk for QT prolongation?

Congenital long QT syndrome Bradycardia Hypokalemia Hypomagnesemia Recent MI Uncompensated HF

What medication is demonstrated to provide the most symptom relief to treat vasomotor symptoms associated with menopause?

Conjugated estrogen

Management of suspected chlamydial conjunctivitis

Conjunctival culture Treat with PO erythromycin x 2 weeks (also in airway, want to avoid PNA)

Chemosis

Conjunctival edema

Antibiotics for severe COPD exacerbation

Consider severity of COPD and cormorbidities in decision-making process Augmentin Cephalosporin Azithromycin (QT prolonging) Clarithromycin (QT prolonging, P450 inh) Moxifloxacin or levofloxacin (respiratory fluoroquinolone, best choice, risk for tendon ruture)

Management of polymyalgia rheumatica

Corticosteroid 10-15 mg per day of prednisone for 2-3 weeks or until symptoms are relieved followed by tapering the dose to find the lowest dose necessary to supress symptoms

COPD sxms

Cough Chronic sputum production Activity intolerance Progressive

S/s of TB

Cough Unexplained weight loss/anorexia Fever Night sweats Hemoptysis Chest pain Fatigue

Claims-made policy

Covers the clinician only if the injury occurs within the policy period and if the claim is filed during the period the policy is in effect - or when an uninterrupted "tail" insurance policy is in effect

Pathogen associated with HFM

Coxsackie virus A16

DDx of stridor in children

Croup (laryngotracheobronchitis) Foreign body Congenital obstruction Peritonsillar abscess Acute epiglottitis

CPT stands for

Current procedural terminology

Underlying comorbidities associated with genital candida albicans in men

DM HIV

DSM-5 criteria for autism spectrum disorder

Deficits in 2 core domains: 1. Persistent deficits in social communication and social interaction across multiple contexts, with notable deficits in social-emotional reciprocity, nonverbal communication behaviors, developing, maintaining, understanding relationships 2. Restricted, repetitive patterns of behavior like sterotyped motor movements, insistence on sameness, highly restricted interests, hyper or hypoactivity to sensory inputs

Nonmaleficence

Defined as the requirement that the healthcare provider do no harm, whether with or without intention If harm is unavoidable, the provider is obligated to minimize harm

Treatable causes of urinary incontinence - "DIAPERS"

Delirium Infection (urinary) Atrophic urethritis and vaginitis Pharmaceuticals (diuretics, etc.)/Psychologic disorders Excessive urine output Restricted mobility Stool impaction

Onset of delirium vs. dementia

Delirium: Abrupt onset, over hours to days, usually a precise date, rapidly progressive change Dementia: Insidious onset

Memory impairment in delirium vs. dementia

Delirium: Impaired but variable recall Dementia: Memory loss, especially for recent events

Reversibility of delirium vs. dementia

Delirium: Usually reversible to baseline mental status when underlying illness resolves Dementia: Chronically progressive and irreversible

How is hyperparathyroidism diagnosed

Diagnosis typically by elevated serum calcium without other obvious cause, confirmed by elevated PTH Additional testing includes 24h urine calcium to determine disease severity

Informed consent

Disclosure of appropriate information to a competent patient who is permitted to make a voluntary choice

Common immunization adverse effects

Discomfort Erythema at immunization injection site common and expected This is an immune response to an injected antigen Kids have a more noted response because they have a more robust/active immune system Can use Benadryl cream if itchy

S/s of roseola

Discrete rosy-pink macular or maculopapular rash lasting hours to 3 days that follows a 3-to-7 day period of fever, often quite high 90% of cases seen in children <2 Febrile seizures in 10% of children affected

Etiology of meniscal tear

Disruption of the meniscus, a C-shaped fibrocartilage pad located between the femoral condyles and the tibial plateaus Often found in athletes due to the twist-type injury to the knee

Sleep disturbance in dementia

Disturbed sleep-wake cycle but lacks hour-to-hour variability, often day-night reversal

Sleep disturbance in delirium

Disturbed sleep-wake cycle with hour-to-hour variability, often worse as the day progresses "Sundowning"

Diverticulosis vs. diverticulitis

Diverticulosis is pouches in the colon wall. These should be distinguished from diveritculitis, which refers to inflammation or infection of the diverticula and is a complication of diverticulosis Most people have a few diverticula in the colonic wall by the age of 50

12 month old developmental warning signs

Doesn't crawl Can't stand when supported Doesn't search for things that she sees you hide Doesn't say single words like "mama" or "dada" Doesn't learn gestures like waving or shaking head Doesn't point to things Loses skills he once had

18 month developmental warning signs

Doesn't point Can't walk Doesn't know what familiar things are for Doesn't copy others Doesn't gain new words Doesn't have at least 6 words Doesn't notice or mind when a caregiver leaves or returns Loses skills he once had

2 month old developmental red flags

Doesn't respond to loud sounds Doesn't watch things as they move Doesn't smile at people Doesn't bring hands to mouth Can't hold head up when pushing up on tummy

6 month developmental warning signs

Doesn't try to get things that are in reach Shows no affection for caregivers Doesn't respond to sounds around him Has difficulty getting things to mouth Doesn't make vowel sounds Doesn't roll in either direction Doesn't laugh or squeal Seems very stiff or very floppy

2 year old developmental warning signs

Doesn't use 2 word phrases Doesn't know what to do with common things Doesn't copy Doesn't follow simple instructions Doesn't walk steadily Loses skills once had

4 month old developmental warning signs

Doesn't watch things as they move Doesn't smile at people Doesn't hold head steady Doesn't coo or make sounds Doesn't bring things to mouth Doesn't push down with legs when feet are placed on a hard surface Has trouble moving one or both eyes in all directions

Antimicrobial choices for individuals with beta-lactate allergy (allergy to antimicrobials with beta-lactate ring, such as penicillins and cephalosporins) for ABR

Doxycycline 200 qday Levofloxacin 500 mg P.O. daily Moxifloxacin 400 mg P.O. daily You should choose a fluoroquinolone if you fear DRSP gram negative organisms

How is fifth's disease transmitted

Droplet transmission Leukopenia common

When would a patient receive epoetin alfa (EPO, procrit)?

Drug that is biologically identical to endogenous erythropoietin -- induces erythropoiesis Helpful in severe anemia, particularly presence in advancing renal failure (erythropoietin is diminished when GFR <49)

Adverse effects from anticholinergic meds

Dry mouth, skin Blurred vision Urinary retention (common in older men with BPH) Sedation Agitation Tachycardia Hyperpnea Mydriasis Flushing (if OD) Psychosis (if OD) Seizure Coma Hypernatremia "Dry as a bone, red as a beet, mad as a hatter, hot as a hare; can't pee, cant spit, cant see, can't shit."

Duodenal ulcer vs. gastric ulcer

Duodenal ulcer better with food - cause typically H. pylori (stool antigen or urea breath test) Gastric ulcer worse with food - cause typically NSAIDs and corticosteroids

Pathogens associated with acute, uncomplicated urinary tract infection in nonpregnant women

E. coli (gram neg, most common) Klebsiella supp. (gram neg) S. saprophyticus (gram +)

Diagnostic studies when HF is suspected

EKG CXR Echo Hgb BMP TSH

Diagnostic tests for reactive arthritis

ESR CRP HLA-B27 gene Xrays can be used to indicate the presence of characteristic signs of reactive arthritis Test for GC and chlamydia

Hormonal changes in menopause

Early FSH elevation (induce hot flashes) FSH and LH rise dramatically as anterior pituitary attempts to induce ovulation Ovaries fail to respond with ovulation, sometimes leading to heavy, anovulatory menstrual bleeding Estrogens and androgens are reduced

What is secondary prevention?

Early case finding of a symptomatic disease via the use of a screening test Diseases we screen for have a long asymptomatic period with a known natural history ex. HTN, dyslipidemia, pap

What derm condition are you likely to find on the antecubital fossa?

Eczema

Common adverse effects of TZD

Edema HF Fractures

Information reviewed during NP credentialing

Education Certification Licensure Background check Work history and employment background check National practitioner data bank Status of clinical or hospital privileges associated with former employer

S/s of meniscal tear

Effusion with knee tightness and stiffness ROM limited by discomfort Those with larger tears often report that the knee locks, makes a popping sound, or gives out + McMurray + Apley grind test

Primary hyperparathyroidism etiology

Elevated level of PTH (which regulates calcium levels) results in hypercalcemia. From overactivity of >1 of 4 parathyroid glands by hyperplasia or benign adenoma or malignant tumor

Management of the febrile neonate (<28 days)

Empiric parenteral abx + admission to hospital for evaluation of neonatal sepsis

AEs associated with estrogen replacement therapy

Endometrial cancer risk (unless woman has undergone a hysterectomy, should also take a progestin) Breast cancer CVD Blood clots Transdermal estrogen use associated with lower thromboembolic risk

E&M codes ending with -1X indicate

Est patient encounter

S/s of acute appendicitis

Epigastric and discomfort and anorexia that gradually shifts to nausea and RLQ abd pain + Psoas, obturator, McBurney

Causes of chronic blood loss

Erosive gastritis Menorrhagia GI malignancy Etc.

Best SSRI to use in the older adult because of DDIs

Escitalopram

DDx for partial esophageal obstruction that is bleeding

Esophageal carcinoma Esophagitis Esophageal stricture

HIPAA (Health Insurance Portability and Accountability Act)

Est 1996 Protects patient information

Risk factors for pancreatitis

EtOH abuse, cholecystitis, specific medications

Etiology of Kawasaki Disease

Etiology unconfirmed Peak incidence in toddler ages Seasonal variations (late winter/early spring) Widespread inflammation of small and medium-size arteries

Rubella incubation period and transmission

Incubation: 14-21 days Transmissible for ~1 week prior to rash onset and to ~2 weeks after rash appears

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor examples

Evolocumab, alirocumab Subq injection only $20,000/y

How frequently should you recalculate the estimated ASCVD risk for individuals not receiving cholesterol lowerin gdrugs?

Every 4-6 years in individuals aged 40-75

Sulfonylurea MOA and example

Ex. glipizide Constant insulin release, like basal insulin

GLP-1 agonist example and MOA

Exenatide (Byetta), Victoza Insulin release post glucose rise Slowed gastric emptying

Latino view of healthcare providers

Expectation that healthcare providers will be attentive, show respect, provide information and instruction Will not be just about business but will also inquire about family

Asian view of healthcare providers

Expected to make decisions and give instructions

Risk factors for COPD

Exposure to irritants including tobacco, occupational exposure FHx Advancing age

Example of selective cholesterol absorption inhibitor

Ezetimibe (Zetia)

When should you screen children for dyslipidemia?

FHx of dislipidemia Premature <55 FHx of CVD Overweight Obesity HTN Smoking DM Screen with fasting lipid profile after 2 years of age and no later than 10 If values within reference range, retest in 3-5 years

3 year old developmental warning signs

Falls down a lot or has trouble with stairs Drools or has unclear speech Can't work simple toys Doesn't speak in sentences Doesn't understand simple instructions Doesn't play pretend or make-believe Doesn't want to play with other children or with toys Doesn't make eye contact Loses skills once had

Diagnosis of "prediabetes" or impaired fasting glucose

Fasting glucose 100-125 IGT 140-199 A1c 5.7-6.4%

Diagnosis of DM

Fasting plasma glucose >126 mg/dL Random glucose > 200 with polys, weight loss, hyperglycemic crisis 2h plasma glucose >200 after 75 g glucose test A1c >6.5% - repeat recommended in asymptomatic adult with glucose <200

Iron supplementation in pregnancy

Fe in prenatal vitamins/normal diet sufficient if Hgb >11 If Hgb <11 in second trimester of <10.5 in third, 30 mg elemental iron orally per day Also check to make sure zinc and copper on board Avoid over-supplementation due to risk for oxidative damage

Causes of transmission of Hep A

Fecal contaminated food or water: - Close person to person contact with an infected person - Sexual contact with an infected person - Ingestion of contaminated food or drinks

Vertigo

Feeling that surroundings are moving; sensation of motion even when eyes are closed Usually caused by crystals in inner ear becoming displaced and incorrectly stimulating nerve cells within the semicircular cannals

Components of the biophysical profile

Fetal breathing movements Gross body movements Tone Amniotic fluid index Nonstress test Each component scored as either 0-2, with a maximum score of 10

Prenatal care 32-36 weeks

Fetal presentation Kick count (should have fetal movements >4 in 1 hour or >10 in 2 h; report decrease)

S/s of rubella

Fever S/t Malaise Nasal discharge Diffuse maculopapular rash lasting hours-3 days followed by 3-7 days of high fever

S/s of kawasaki disease

Fever >104F lasting >5 days Polymorphic exanthem on trunk, flexor regions, and perineum Erythema of the oral cavity "strawberry tongue" Bilat conjunctivitis Cervical lymphadenopathy Edema and erythema of the hands and feet

S/s of HFM

Fever, malaise, sore mouth anorexia 1-2 days later will present with lesions Lasts 2-7 dyas

Microscopic exam findings in in genitourinary syndrome of menopause AKA atrophic vaginitis

Few or absent lactobacilli

Chancre

Firm round painless genital and/or anal ulcer with clean base and indurated margins, accompanied by localized lymphadenopathy

Naegele's rule

First day of LMP - 3 months + 7 days (adjust for year) Provides a reasonable estimation for the EDD

Cervical cancer screening recommendations for women with hysterectomy without cervical removal

Follow typical screening guidelines

Pathologic split S2

Fixed split - no change in inspiration Paradoxical split - narrows or closes with inspiration Heard best in pulmonic region Fixed split often found in uncorrected septal defect Paradoxical split often found in conditions that delay aortic closure such as LBBB Finding can resolve with treatment of underlying condition

Plagiocephaly

Flattening or asymmetry of the head

What visual change do you expect the patient to report with a diagnosis of proliferative diabetic retinopathy?

Floating spots in visual field

Treatment for a 45 year old woman with pyelonephritis who is otherwise healthy and has no sulfa allergy is

Fluoroquinolone

Treatment of inhalation anthrax or cutaneous anthrax

Fluoroquinolone

1st line treatment for suppurative conjunctivitis

Fluoroquinolone ocular solution

Most energizing SSRI

Fluoxetine

SSRI with longest half life

Fluoxetine (up to 2 weeks)

Adverse effects of niacin

Flushing (can be minimized by taking asa 1h prior to dose) Hyperglycemia Hyperuricemia Upper GI distress Hepatotoxicity

Pathophysiology of acne vulgaris

Follicular epidermal hyperproliferation with subsequent follicle plugging, excess sebum production, presence of P. acnes, accompanying inflammation

L4 motor/reflex/sensation

Foot dorsiflexion Knee jerk reflex Medial calf sensory

S1 motor/reflex/sensation

Foot eversion Ankle jerk Lateral foot sensory

For a woman initiating bisphosphonate therapy for osteoporosis, treatment should continue

For 5 years

When would you use the slit lamp exam?

For evaluation of anterior eye structures, including cornea, conjunctiva, sclera, and iris

Straight leg raise test

For lumbar nerve root compression

Apley grind test

For meniscal tears, flex patient's leg to 90 degrees, then grind the tibial condyles against the femoral condyles with rotation motion in the varus and then valgus positions.

Newborn feeding recommendations

Formula: 1.5-3 oz (45-90 mL) every 2-3 h Breastfeeding: Every 1.5-3 hours, no more than 4 hours without feeding

2 month old feeding recommendations

Formula: 4-5 oz (120-150 mL) every 2-4 h Breastfeeding: At least 7-9x per day, usually as dictated by infant (every 3-4h)

4 month old feeding recommendations

Formula: 4-6 oz (120-180 mL) every 3-4 h Breastfeeding: 6-8x per day, as dictated by infant (every 3-4h)

What diagnosis should you consider if a male patient presents with unusually large testes?

Fragile X syndrome

Management of maternal morning sickness

Frequent small meals Avoid high-fat or large meals that can further delay gastric emptying Avoid aggravating foods Keep track of foods that worsen symptoms Avoid rapid intake of large amounts of liquids Frequent sipping on liquids helps to maintain fluid balance Avoid high fat liquids Supplement: B6, ginger For intractable: phenergan, reglan, zofran (first line)

Onset of physiologic jaundice in the newborn

From the breakdown of RBC after the baby is born NEVER occurs in first 24h of life

2 month old developmental milestones "2, 2, 2"

From tummy, can lift self up on 2 arms Responds to 2 sounds Smiles when smiled 2 Can calm self Tries to look at parent Coos, makes gurgling sounds Turns head toward sounds Pays attention to faces Follows things with eyes and recognizes people at a distance Acts bored if activity doesn't change Can hold head up and begins to push up when lying on tummy Makes smoother movements with arms and legs

Pick's disease

Frontotemporal dementia (FTD), or Pick's disease, is a syndrome featuring shrinking of the frontal and temporal anterior lobes of the brain. The symptoms of frontotemporal dementia fall into two clinical patterns that involve either: (1) changes in behavior, or (2) problems with language.

Adverse effects of metformin

GI upset Lactic acidosis

Classification of severity of airflow limitation (GOLD)

GOLD 1 = Mild = FEV1 > 80% (usually undiagnosed) GOLD 2 = Moderate = FEV1 50-80% (usually undiagnosed) GOLD 3 = Severe = FEV 30-50% GOLD 4 = Very severe = FEV <30%

Weight effect of sulfonylureas

Gain

Weight effects of TZD

Gain

GI side effects of using long term NSAIDs and corticosteroids are primarily...

Gastritis and gastric ulcer

Examples of fibric acid derivatives (fibrates)

Gemfibrozil, fenofibrate, fenofibric acid

With what % BSA burn should you refer to specialty burn care?

Genital burns regardless of age >20%

What dietary supplements are associated with increased bleeding risk and should be d/c'd 7-10 days prior to elective surgical procedure?

Ginseng Gingko Fish oil

You are rounding in the nursery and see a neonate of a mother who is HBsAg-Positive. You should...

Give Hep B #1 (passive immunity) and Hep B immune globulin (active immunity)

What sulfonylurea should you avoid in the older adult?

Glyburide due to long half life

What disease do newborns receive ocular chemoprophylaxis for at birth?

Gonococcal conjunctivitis

What is the minimum grade of retinopathy with retinal bleeding?

Grade 3

Palmar grasp reflex

Grasping of an object when placed in the palm. No longer seen by 2-3 months.

Types of hyperthyroidism

Graves' disease (autoimmune) Toxic adenoma (benign, metabolically active thyroid nodule) Thyroiditis (autoimmune or viral, postpartum, drug-inducecd, often transient, usually accompanied by thyroid adenoma) Amiodarone, interferon

L5 motor/reflex/sensation

Great toe dorsiflexion No associated reflex Medial foot sensory

Warning for use of dabigatran in the older adult

Greater risk for bleeding than warfarin in adults >75 Lack of evidence for efficacy and safety in individuals with CrCl <30

Pathogen associated with exudative pharyngitis

Group A , C, G strep Viral (EBV) HHV-6 N. Gonorrhoeae F. Necrophorum

Accountable care organization

Groups of healthcare organizations and clinicians who come together voluntarily to give coordinated high-quality care to Medicare patients

Aldosterone antagonist AEs

Gynecomastia risk with prolonged use (androgen antagonist) Hyperkalemia risk, especially with ACE/ARB concommitant use Not-first line med

Duodenal ulcers are primarily caused by...

H. pylori

Acute disease markers of HBV infection

HBV core IgM ab = earliest marker to become positive post-HBV exposure (denotes acute infection) HBsAg = indicates infection HBeAG = time when extra contagious Elevated hepatic enzymes > 10 ULN

Labs indicative of chronic HepB

HBsAG + Modest elevation in AST/ALT ALT > AST

Thiazide diuretic examples

HCTZ, chlorthalidone

Pathogen associated with acute epiglottitis

HIB (H. influenzae type B)

Risk factors for active TB

HIB+ + PPD Prior TB treatment TB exposure Travel to or emigration from an area where TB is endemic Homelessness, shelter-dwelling, incarceration

Women who should have more frequent Paps

HIV+ Immunosuppressed Exposed to diethylstilbestrol (DES)

HPV strains that cause warts vs. cancer

HPV 6 and 11 associated with warts Others associated with cancer No cross over

What would cause hemorrhagic lesions on eye exam?

HTN DM retinopathy Trauma

Why do pregnant women have morning sickness?

High levels of estrogen and progesterone secreted by corpus luteum Progesterone -- delays gastric emptying, contributes to heartburn, relaxes LES hCG produced by trophoblast on day 8 of pregnancy, has effect on CNS

Where do you expect the fundal height to be at 16 weeks gestation?

Half way between sympthysis pubis and umbilicus

Types of hypothyroidism

Hashimoto (autoimmune) Post-radioactive iodine treatment s/p graves' disease or thyroid cancer treatment Use of lithium, amiodarone, interferon

CAGE questionnair

Have you ever felt you ought to CUT down on drinking? Have people ANNOYED you by criticizing your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang over (EYE OPENER) >2 positive responses has sensitivity of 93% and specificity of 76%

Where does neonatal jaundice begin?

Head --> trunk --> extremities

Calculating BSA (Rule of 9s)

Head and neck = 9% Upper limbs = 9 % Trunk = 4x9 = 36% Genitalia = 1% Lower limbs = 2 x 9 = 18% each

Who is a covered entity under HIPAA

Healthcare providers who electronically transmit health information in connection with a standard transaction (healthcare provider, hospitals, health departments) Health plans Healthcare clearinghouses

Utilitarianism

Healthcare resources are allocated so that the bestis done for the greatest # of people

Leading causes of death in the US

Heart disease Malignant neoplasms Chronic lower respiratory disease

Orthopnea = what until proven otherwise?

Heart failure

Management of Stage A HF

Heart healthy lifestyle Prevent vascular, coronary disease Prevent LV structural abnormalities ACEI or ARB in appropriate patients for vascular disease of DM Statins as appropriate

BP =

Heart rate (HR) x Stroke volume (SV) x PVR (peripheral vascular resistance)

Anxiolytic effect on mood/best use

Helpful in alleviating hypervigilance associated with anxiety, but use does not decrease worry Benzodiazepine Buspirone (BuSpar)

Blood cell progenitor is called...

Hemocytoblast

Treatment for giant cell arteritis/temporal arteritis

High dose systemic corticosteroid therapy (1-2 mg/kg/day prednisone until disease stabilized) followed by reduction in dose that continues for 6 months-2 years Aspirin can be used to reduce risk of stroke Provide GI cytoprotection with PPI or misoprostol Provide bone protection with bisphosphonate

Causes of premature RBC destruction

Hemolysis Shortened RBC lifespan like Sickle cell

Post-exposure prophylaxis for HBV

Hepatitis B immune globulin (HBIG) and HBV immunization for blood, body fluid contacts in nonimmune individuals

Diagnostics in infectious mononucleosis

Heterophil antibody test (monospot) Leukopenia with lymphocytosis and atypical lymphocytes

Prenatal care 28-32 weeks

Hg STI testing as indicated (syphilis, HIV, HBsAg, GC, chlamydia RhoGAM as indicated Update Tdap between 27-36 weeks with each pregnancy

When should you screen young children for IDA

Hgb by age 1 year When Hgb <10, further testing to confirm iron deficiency With anemia of 10-11, treat with iron for 1 month, rise in Hb >1g/dL after a month of iron therapy helps to confirm iron deficiency

Costs of insulin

High

Efficacy of GLP1

High

Efficacy of sulfonylurea

High

Cost of SGLT2

High ~$150 per month

Cost of GLP1

High ~$250/m

Treatment of mild abscess/carbuncle/furuncle

I & D Warm compresses

Medicare A coverage

Hospital services, some home health, hospice, religiously-associated facilities

Management of postpartum psychosis

Hospitalization usually needed for safety of mother and baby Antipsychotics Mood stabilizers Benzodiazepines Antidepressants

Confidence level

How sure you can be that your study results are accurate Ex. if a study asserts that a confidence level of 95%, then you can be 95% confident that on repeated measures, results will fall within the interval

Pathogen associated with roseola

Human herpesvirus-6 (HHV-6)

Pathogen associated with Fifth's disease

Human parvovirus B19

Risk factors for pancreatitic cancer

Hx of chronic pancreatitis Tobacco use Diabetes mellitus

Risk factors for ectopic pregnancy

Hx of salpingitis (most common risk factor) Prior ectopic pregnancy Hx of tubal surgery Assisted reproduction Hx of infertility Cigarette smoking Maternal in utero DES exposure Progestin use Current IUD/IUS use Vaginal douching Tubal ligation failure

Physical exam findings in COPD and asthma exacerbation

Hyperresonance Decreased tactile fremitus (tactile fremitus decreases with decreased tissue density) Wheeze (expiratory first, inspiratory later) Low, flattened diaphragms Increased AP diameter (most common in COPD or with longstanding, poorly controlled asthma)

Effects of target organ damage from HTN on the idney

Hypertensive nephropathy Renal failure

Effects of target organ damage from HTN on the eye

Hypertensive retinopathy with risk for blindness

Etiology of sudden cardiac arrest in young athletes

Hypertrophic cardiomyopathy (1/3) Blunt trauma causing structural changes AKA "cardiac concussion" inducing VF Commotio cordis (chest blow that interrupts cardiac rhythm without visible cardiac injury) Heat stroke (likely due to hyperkalemia induced by extensive tissue damage)

Common adverse effect of sulfonylureas

Hypoglycemia

Common adverse effects with insulin

Hypoglycemia

Treatment of moderate abscess/carbuncle, furuncle

I & D Culture and sensitivity Empiric TMP/SMX or doxy Then therapy directed by C & S results

"Coding" refers to

ICD10 code E&M (evaluation and management) code and CPT code

Management of syphilis

IM penicillin or PO doxycycline in beta-lactam allergy

First-line anti-TB agents that form the core of treatment regiments include...

INH Rifampin Ethambutol Pyrazinamide

Moderate nonpurulent skin condition tx

IV abx

Management of Kawasaki disease

IVIG ASA

What is the risk of iron-supplementing a person with thalassemia minor?

Iatrogenic iron overload

Management of cystitis and urethritis in nonpregnant women

If local E. coli resistance to TMP/SMX <20% and no allergy, then TMP/SMX-DS PO BID x 3 days If local E. coli resistance to TMP/SMX >20% or sulfa allergy, nitrofurantoin 100 mg PO BID x 5 days or fosfomycin 3 g PO x 1 dose Add phenazopyridine (pyridium) PO to help with symptom control 2nd line: ciprofloxacin 250 mg PO BID + pyridium

HBsAg

If positive, evidence HBV on board Ag = "Always growing" HBV persists Noted in either acute or chronic hep B

Anti-HBs/HBSab

If positive, evidence of HBV immunity B = "Bye" - no longer on board

HCV RNA

If positive, evidence of current HCV infection

Anti-HCV

If positive, evidence of past or present HCV infection

Anti-HAV

If positive, immune to HAV includes HAV IgG "G = gone" Usually from vaccination

What immunoglobulin is a marker for active immunity?

IgG "gone"

Post-exposure prophylaxis for HAV

IgG and or immunization for close contacts that are not immune to HAV

What immunoglobulin is a marker of acute disease?

IgM "miserable"

First line treatment for verruca vulgaris

Imiquimod cream (immune modulator)

Treatment for patients with AR who have inadequate response to symptoms with pharmacological therapy with or without environmental controlls

Immunotherapy (sublingual or subQ) through specialty allergist referral Restore tolerance to allergen by reducing its tendency to induce IgE production

CCB MOA

In coronary and peripheral arterial smooth muscle and the heart, inhibition of Ca2+ entry blunts the ability of Ca2+ to serve as an intracellular messenger leading to arterial vasodilation

Speech changes in dementia

In earlier stages, word searching, progressing to sparse speech content Mute in late disease

This term refers to the number of new cases of a condition occurring within a period of time

Incidence

Internal validity

Includes research design/protocol and steps of the scientific method Great results are invalidated by sloppy or poor design

Speech changes in delirium

Incoherent Confused Wide variety of inappropriately used words, such as misnamed persons and items

Cause of infantile communicating hydrocele

Incomplete sealing of peritoneal cavity at inguinal area during gestation, leaving communication between abdominal cavity and scrotum

Transient incontinence

Incontinence that occurs during an acute illness

A newly pregnant woman with hypothyroidism presents to your clinic for initial evaluation. How should you manage her levothyroxine?

Increase dose by ~33% as soon as pregnancy is confirmed

Why should sleep aids/sedatives (like zolpidem) be avoided in the older adult (Beer's criteria)?

Increase in fall and fracture risk

Dietary approaches to decrease LDL-C

Increase viscous or soluble fiber, plant stanols, sterols

Change in vaginal pH in BV

Increased 5-7

What does a laterally displaced PMI indicate?

Increased LV volume

Cause of deeply cupped optic disc caused by excessive intraocular pressure

Increased intraocular pressure

Why should SSRIs be avoided in the older adult? (Beer's criteria)

Increased risk for hyponatremia, especially. when used with diuretic If starting, check Na after 1 month on medication

Adverse effects of fish oil supplementation

Increased risk of bleeding due to modest antiplatelet effect GI upset including "fishy" taste

Risk for prolonging the QT interval

Increases risk for VTach and sudden cardiac death

Rubeola incubation period and transmission

Incubation: 10-14 days Transmissible for ~1 week prior to onset and ~2-3 weeks after rash appears

Should statins be started or continued in the older adult?

Individuals over age 80 are at increased risk of statin-related adverse effects like rhabdo USPSTF: Insufficient evidence to initiate statin use for adults >76 High benefit > risk ratio in individuals >85 with established CVD or with DM, CKD

Hale's rule

Infant receives <1% of maternal drug dose through breastmilk

Erysipelas

Infectiionn of the upper dermis, supericial lymphatics Usually includes heat, redness, and discomfort in the region Caused by Strep. Pyogenes Requires systemic antimicrobial therapy

Etiology of reactive arthritis

Infection like n. gonorrhoeae and c. trachomatis

CAP

Infection of lungs and bronchi acquired while residing in community (not hosp or long term care)

Cellulitis

Infection of the dermis and subcutaneous fat that usually includes heat, redness, and discomfort in the region Either caused by MRSA or MSSA

Pelvic inflammatory disease

Infectious, inflammatory disorder of the upper female reproductive tract, including uterus, fallopian tubes, adjacent pelvic structures

Causes of vertigo

Inflammation of inner ear Meniere's diseae Head trauma Stroke MS Tumors Migraine

Balanitis

Inflammation of the glans penis

1st line controller therapy to prevent AR symptoms

Intranasal corticosteroids through prevention of inflammatory mediators (Flonase, nasacort)

Management of IBD

Lifestyle modifications can improve sxms Aminosalicylates Corticosteroids Immune modulators Surgical intervention often needed Careful monitoring for GI malignancy

Primary headache treatment options

Lifestyle modifications, analgesics, migraine-specific medications, prophylactic medications, rescue therapy

Selective cholesterol absorption inhibitor AEs

Limited systemic absorption No dose adjustment required for renal or hepatic dysfunction When combined with simvastatin = Vytorin

Orthopedic ddx in the otherwise well patient

Limited to bones and joints

Labs that are elevated in acute pancreatitis

Lipase, amylase

ACE-I examples

Lisinopril, enalapril

Beta blocker AEs

Lower dose cardioselective beta blocker therapy acceptable in COPD, asthma but avoid non-cardioselective beta blockers that block beta-2 receptors (like propranolol and nadolol) in lower-airway disease Small clinical effect, not first line

6 month old developmental milestones

Looks like a #6 when sitting up, tripod positioning Can roll in a 6 - from back to tummy and back Now no need for tummy time Knows familiar faces and knows if someone is in danger Responds to other's emotions Likes to look at self in mirror Responds to sounds by making sounds Strings vowels together when babbling Uses consonant "m" and "b" Responds to own name Makes sounds to show joy and displasure

ARB examples

Losartan, telmisartan

Weight effects with GLP1

Loss

Weight effects of SGLT2 ihibitor

Loss (~4 lb.)

Grade 4 murmur

Loud with thrill (tremor or vibration on palpation)

Cost of TZD

Low

Hypoglycemia risk

Low

Hypoglycemia risk of GLP1

Low

Metformin hypoglycemia risk

Low

SGLT2 inhibitor hypoglycemia risk

Low

Hypoglycemia risk of TZD

Low No effect on insulin release

What is the most common electrolyte disturbance in the older adult?

Low Na

Sequalae of IUGR

Low apgar scores Meconium aspiration Hypoglycemia Poor body temperature regulation Polycythemia Intrauterine asphyxia

Medical therapy for menopausal vasomotor symptoms when a woman cannot take estrogen replacement therapy

Low dose SSRI and SNRI can reduce the frequency and severity of hot flashes by 35%

S/s of inhalation anthrax

Low grade fever Non productive cough Widened mediastinum due to hemorrhage visible on CXR Hx of inhalation of bacillus anthracis spores during exposure to contaminated animal wool, hair, hides, bioterrorism

Diagnostic labs for secondary hyperparathyroidism

Low normal serum calcium Elevated PTH Presence of severe renal dysfunction or severe vitamin D deficiency

Cost of sulfonylurea

Low, $4

Metformin cost $

Low, $4

Most likely WBC response in significant viral infection

Low-normal TWBC Predominant form lymphocyte with reactive forms

What does of fish oil should you recommend for TG lowering effect?

Lower by 20-30%, increased HDL 1-5% 4g/d

Order of heart valve closure

MTAP Mitral Tricuspid Aortic Pulmonic

S/s of infectious mononucleosis

Maculopapular rash in ~20% Rare petechial rash Fever Shaggy purple white exudative pharyngitis Malaise Marked diffuse lymphadenopathy Hepatic and splenic tenderness with occasional enlargement

Tanner stage 4

Males: Increase in penil length and width with development of the glads; further darkening of the scrotal skin; adult type pubic hair Females: Aerola and papilla elevated to form a second mound; adult type pubic hair - menarche Peak of growth spurt

Tanner stage 2

Males: Testes enlarge, scrotal skin reddens with change in texture, sparse growth of long, slightly pigmented pubic hair Females: Breast buds and papilla elevated, downy pigmented pubic hair along labia majora

Tanner stage 3

Males: increase in penile length "pencil penis", further scrotal enlargement, pubic hair darker, coarser, onset of growth spurt Females: Breast mound enlargement, darker, coarser, curling pubic hair on mons, labia majora, onset of growth spurt

Diagnostic testing for TB

Mantoux (screen) Quantiferon Gold (screen) Acid-fast bacilli smear or culture from sputum sample Enzyme-linked immunospot assay for mycobacterial ribosomal RNA CXR Thoracic CT HIV testing if status unknown

Confidence interval

Margin of error Desired confidence interval is one of the factors that goes into calculation of sample size Shows the range in which the response is likely to be accurate

Pathologic S4

Marker of poor diastolic function, most often found in poorly controlled HTN or recurrent myocardial ischemia Stiff ventricle Best heard with bell "Tennessee"

Pathologic S3

Marker of ventricular overload and/or systolic dysfunction "Kentucky" Low pitch, best heard with bell For diagnosis of HF, correlate with additional findings such as dyspnea, tachycardia, crackles Also found on pregnancy

S1 heart sound

Marks the beginning of systole Closure of mitral (L) and tricuspid (R) valves Best heard at apex with diaphragm "LUB dub"

S2 heart sound

Marks the end of systole Closure of aortic (L) and pulmonic (R) valves Best heard at base of heart with diaphragm "lub DUB"

S/s of acute epiglottitis

Most often sen in children ages 2-7y Abrupt onset high-grade fever, sore throat, dysphagia, and drooling

Components of quad screen

Maternal serum hCG levels (produced by placenta) AFP levels (produced by fetal liver) Unconjungated estriol (produced by placenta and fetal liver) Inhibin-A (produced by placenta)

6 month old feeding recommendations

May transition to solid foods Formula: 6-8 oz (180-230 mL) every 4-5h while awake Breastfeeding: 4-6x per day while awake

Tonometry

Measurement of intraocular pressure, glaucoma screening test

Thyroid peroxidase antibody (TPO Ab)

Measures an antibody against peroxidase, an enzyme in the thyroid. Helps to diagnose autoimmune disease. NL <35

Hypothyroidism: Mom's so tired

Memory loss Obesity (mostly water) Menorrhagia Slowness Skin and hair dryness Onset gradual Tiredness Intolerance to cold Raised BP Energy levels fall Depression/delayed relaxation of all reflexes

Lifestyle triggers influencing the onset or severity of migraine or other primary HA symptoms

Menses/ovulation/pregnancy Illness Strenuous activity Altered sleep patterns Altered eating patterns Bright or flickering lights Excessive or reptitive noises Odors Weather changes High altitudes SSRI/SNRI Analgesic overuse Stress

Characteristics of perimenopause

Menstrual irregularity Ovulation irregularity - pregnancy still possible Hot flashes and sleep problems worse in the week before the menses Estrogen levels normal FSH elevated

Management of preeclampsia

Methyldopa/CCB/Beta blocker if SBP >160/DBP >110 Mag ASA 81 mg/day after 12 weeks gestation in high-rsik women Consider labor induction if >37 weeks

Management of trichomoniasis

Metronidazole 2g PO or tinidazole 2 g PO as a 1 time dose Patients should be advised to avoid consuming alcohol during treatment with oral metronidazole for 24h after completion of metronidazole d/t GI upset Alternatively metronidazole 500 mg PO BID x 7 days

Management of BV

Metronidazole topical or oral Clindamycin vaginal cream Tinidazole oral

Nonproliferative diabetic retinopathy AKA background retinopathy

Microaneurysms with or without bleeding, hard exudates. Severe cases - retinalhemorrhage, cotton-wool patches, beading of retinal veins, tiny tortuous retinal vessels Macular edema possible

Adverse effects of protracted PPI use

Micronutrient malabsorption (B12, calcium, magnesium, iron) Increased fracture Pneumonia C. diff-associated diarrhea use

Characteristics of mitral valve prolapse

Midsystolic click with late systolic murmur that moves forward with position to change from supine to standing

S/s of migraine with aura

Migraine type HA occurs with or after aura Focal dysfunction of cerebal cortex or brain stem causes >1 aura symptom to develop over 4 minutes or >2 symptoms in succession No aura lasts for >1h Aura characteristics: Dread/anxiety, fatigue, nervousness, excitement, GI upset, visual/olfactory alteration Lasts 4-72h w/ >2 of the following characteristics - Unilateral location - Pulsating quality (mod-severe) - Aggravation by normal activity During headaches, note >1 of the following - Nausea/vomiting - Photophobia - Phonophobia Female: male ratio 3:1 + FHx in 70-90%

S/s of ovarian cancer

Minimal, nonspecific sxms in early stage Bloating Bladder pressure Constipation Vaginal bleeding Indigestion SOB Lethargy Weight loss

Recommended length of CAP therapy

Minimum 5 days with evidence of increasing stability, afebrile for 48-72 hours prior to antimicrobial discontinuation

What medicine for overactive bladder has the least anticholinergic effect?

Mirabegron (myrbetriq)

Systolic murmurs: MR. PASS

Mitral Regurgitation Physiologic (innocent, function) Aortic Stenosis Systolic

Diastolic murmurs: MS. ARD

Mitral Stenosis Aortic Regurgitation Diastolic

Most common "rumbling" murmur

Mitral stenosis

Hypoglycemia risk with sulfonylureas

Moderate

Grade 3 murmur

Moderately loud without thrill (about as loud as S1 or S2)

S/s of cutaneous anthrax

Most common form Pustular skin lesion that eventually forms ulcer with eschar

Etiology of pediatric IDA

Most common in children ages 12-30 months In children <9 months, Depletion of birth iron stores (lasts until 6 months of age) Initiation of lower iron diet in later infancy Cow's milk intake in excess of 16 oz. per day in children >12 months

Drug -mab suffix

Monoclonal antibody derived Biologic

Schedule II drugs

Morphine Fentanyl Methadone Oxycodone Methylphenidate Anabolic steroids

Post partum depression

Most common at 2-4 months post partum but can occur at any time in 1st year after giving birth Characterized by depressed mood for >2 weeks with change in appetite, sleep disturbance, guilt, worthlessness Risk for SI, not HI

Fragile X syndrome

Most common cause of autism Males: Large forehead, ears, jaw, large testes, large body habitus, learning and behavioral differences Females: Less common, less common findings

S/s of diverticulitis

Multiday history of intermittent LLQ abdominal pain accompanied by fever, cramping, nausea, and 4-5 loose stools per day Soft abdomen + BS + LLQ abd palpation - Blumberg's sign + Leukocytosis with neutrophilia

Most common "blowing" murmur

Murmur of aortic regurg

Microscopic exam of vaginal discharge findings in candida vulvovaginitis

Mycelia Budding yeast Pseudohyphae w/ KOH prep

Pathogens associated with acute bacterial prostatitis age <35

N. gonorrhoeae, C. trachomatis

Pathogens associated with PID

N. gonorrhoeae, C. trachomatis, bacteroides, enterobacteriaceae, streptococci

Common adverse effects with GLP1

N/v Injection - pain

What is the reticulocyte percentage?

NL 1-2% The body's normal response to anemia is to attempt correction via increasing the # of young RBCs >2% indicates reticulocytosis as a response to anemia

Chronic disease markers of HBV infection

NL or slightly elevated epatic enzymes ABsAg positive Others may be negative

Management of moderate-to-severe AD

NMDA receptor antagonist memantine (namenda) Donepezil/Aricept Second generation antipsychotics if environmental manipulation fails to eliminate agitation or psychosis

Management of neuropathy

NSAIDs Antiseizure Antidepressants Lidocaine patch Opioids TENS units

Management of reactive arthritis

NSAIDs and antibiotics

Analgesics for HA

NSAIDs, acetaminophen Triptans for migraine adn tension HA that does not respond to analgesic therapy and cluster HA Best taken at HA onset Limit use to 2 treatment days per week to avoid rebound HA

A first-generation antihistamine can help alleviate all of the following symptoms of allergic rhinitis except: - Sneezing - Nasal congestion - Rhinorrhea - Itchy, watery eyes

Nasal congestion

Considerations for antimicrobial choice when treating ABRS

Need activity against gram + (S. Pneumoniae, consider DRSP risk) and gram - (H. Influenzae, m. Catarrhalis, consider beta-lactamase production risk) High-dose amoxicillin needed against drug-resistant S. Pneumoniae. Clavulanate acts as beta-lactamase inhibitor. Doxycycline has DRSP treatment failure risk with activity against gram negative.

Individual susceptible to hepatitis B infection

Negative HBsAG Anti-HBc negative ABsab negative

Characteristics of functional/benign murmur

Negative hx Lower grade (<gr III/VI) No radiation beyond the precordium S1, S2 intact No heave or thrill PMI WNL Softens or disappears with supine to stand position change

Causative organism in gonoccal urethritis and vaginitis

Neisseria gonorrhoeae (gram neg)

Proliferative diabetic retinopathy

Neovascularization is new vessel formation that looks like radiating spokes. New vessels form

Diagnosis of peripheral neuropathy

Nerve damage identified via nerve function test (electromyography) or nerve biopsy

Causes of age related anosmia/hyponosmia

Neural degeneration, accelerated by tobacco use

Common etiology of syncope

Neurally mediated, including vasovagal (from fear, pain, anxiety, prolonged standing, warmth) Situational syncope (cough, defectation, micturition, swallowing) Cardiac outflow obstruction (hypertrophic cardiomyopathy, valvular in aortic stenosis, aortic dissection, dysrhythmia, SVT, prolonged QT interval, AV heart block) Orthostatic hypotention (dehydration, TCas, CCBs, diuretics, alcohol, etc.)

Weight effects of DPP-4 inhibitor

Neutral

Metformin impacts on weight

Neutral/weight loss

Mneumonic to help recall cell lines and order of reporting: Nobody likes my educational background

Neutrophil (AKA poly or segs, bands are young neutrophils) - 60% of diff Lymphocyte - 30% Monocyte - 6% Eosinophil - 3 % Basophil - 1 %

What WBC do you expect to find in the CSF in a bacterial meningitis? Viral?

Neutrophil; lymphocyte

E&M codes ending with -0X indicate

New patient encounter

Psychomotor changes in dementia

No changes until late in disease

L3 medications

No controlled study or controlled study shows minimal, non-life threatening risk TMP-SMX FQ abx 1st generation antihistamines Doxycycline

Diagnostics in lumbar spinal stenosis

No diagnostics initially needed unless sxms persist >1 month For sxms >1 month, MRI, EMG, Nerve conduction velocity

Proper breastfeeding latch

No dimpling of babys cheeks No clicking sound wit sucking Mouth covers areola Lips are flanged out

How should you modify vaccine administration for an adult who has a hive-form reaction when exposed to eggs (no hx of angioedema or respiratory distress)?

No modification Administer any vaccine appropriate for age and health status

Definition of menopause

No naturally occurring menses in a period of 12 months

Perceptual disturbances in dementia

No perceptual disturbances until later in disease

L1 medications

No risk in lactation Acetaminophen Penicillins Deproprovera

Characteristics of latent TB

No s/s of active infection Still infectious - can spread to others + PPD/Quantiferon/TST >50% lifetime risk of developing active TB

Treatment for "Dry" macular degeneration

No treatment available Avoid risk factors Develops over decades

You diagnose an individual as being an asymptomatic GAS carrier. What is the best next step?

No treatment recommended

Should you use ASA as primary prevention for a cardiac event in the older adult?

No; lack of evidence of benefit versus risk in individuals > 80

Management of Stage 1 HTN with 10 y CVD risk >10%

Non pharmacologic therapy Initiate monotherapy with thiazide diuretic, CCB, ACE/ARB Goal <130/80 Reassess 1 month

Management of Stage 1 HTN with 10 y CVD risk <10%

Non pharmacologic therapy May consider initiation of monotherapy with thiazide diuretic, CCB, ACE/ARB Goal <130/80 Reassess 3-6 months

Management of elevated BP (120-129/<80)

Non-pharmacologic therapy Reassess in 3-6 months

Markers of chronic HAV infection

None Chronic HepA does not exist

Management of Stage 2 HTN

Nonpharmacologic therapy Initiate 2 first line agents of different classes from thiazide, CCB, ACE/ARB Reassess in 1 month

S/s of secondary syphilis

Nonpruritic skin rash, often involving palms and soles, as well as mucous membrane lesions Fever Lymphadenopathy S/t Patchy hair loss HA Weight loss Muscle aches Fatigue

Bile acid sequestrant AEs

Nonsystemic No hepatic monitoring required GI distress Constipation Decreased absorption of other drugs if taken within 2h of other medications

Neuro exam findings for primary headache

Normal neuro exam between headaches Only acceptable neruo findings during headache: Photophobia, phonophobia

S/s of mild dehydration (3-5%)

Normal turgor Normal fontanels Slightly dry lips Thick saliva Tears present Cap refill <1.5 s Normal mental status Slightly decreased urine output Normal to slightly increased thirst

Physiologic split S2

Normal variant finding in younger adults Widening of normal interval between aoertic and pulmonic components of the second heart sound caused by a delay in the pulmonic component Split INcreases on patient INspirationn Found in the majority of adults <30

Causes of primary headache

Not associated with other disease LIkely complex interplay of genetic, developmental, and environmental risk factors Migraine Tension-type Cluster

S/s of peripheral neuropathy

Numbness and tingling in hands and feet with gradual onset Sharp, burning, electric like pain Muscle weakness Sensitivity to touch Hx of DM, traumatic injuries, infections, exposure to toxins

Absolute risk reduction

Numerical risk in a control group - numerical risk in a treatment group #control - #treatment

Causes of reduced RBC production leading to anemia

Nutritional deficit Anemia of chronic disease Bone marrow suppression Reduced erythropoietin production (chronic renal failure)

Nonpharmacologic management of gestational diabetes

Nutritional therapy is 1st line Avoid single large meals and foods with large % of simple carbs 6 feedings perday preferred Complex carbs not to exceed 50% Increased physical activity to >30 minutes per day/>5 days per week No more than 48h without exercise

In the first year of life, infants are ________ breathers

Obligate nasal breathers This is why nasal congestion can result in distress

Antimicrobial choices in children with ABRS

Observation for 0-72 hours, if worse at 72 hours: amox/augmentin 80-90 mg/kg/d If no improvement on augmentin, change to clindamycin AND cefixime OR linezolid AND cefixime OR levofloxacin

Management of chronic HepB

Obtain viral load # Obtain HepB genotype Refer to ID

Presentation of hemangioma

Often not present at birth, but presents soon thereafter Rapid growth from first days of life to 6 months Lesion grows more rapidly than baby does Slow proliferation for 6-12 months then involutation phase from 12 months to 3-6 years

When will you see macrocytosis without anemia?

Old antipsychotics/antispasmotics like carbamazepine, valproic acid, phenytoin, AZT, other drugs Alcohol This is reversible when use of offending medication is discontinued but usually is not a reason to curtail the drugs use, except for excessive alcohol intake

Risk factors for endometrial cancer

Older age Estrogen therapy Nulliparity Obesity Tamoxifen use Hx of breast or ovarian cancer PCOS T2DM Family Hx

8 month developmental milestones

Once able to sit up, child can transfer objects from hand to hand This may happen earlier Babbles (think of holding a toy that looks like an 8) May be afraid of strangers Understands "no" Can use thumb and index finger Pulls to stand Crawls

What tests should you obtain prior to starting contraception?

Only BP for COC/P/R Bimanual exam, cervical inspection, diaphragm or cervical cap for IUD and cervical cap Women (adolescents) often not comfortable with pelvic exam, avoid seeking contraception due to this Coming back for a second or more visit to receive test results erects an artificial barrier

How do you know that someone is not competent to be offered informed consent?

Only a court can declare a person incompetent and appoint a guardian to make decision for the individual Generally going to court not necessary, especially if the family and healthcare provider agree the patient cannot make an informed decision

Onset of action, peak, duration for long acting insulin (insulin detemir and insulin glargine)

Onset: 1-2 h Peak: None Duration: 24 h

Onset of action, peak, duration for intermediate acting (used BID) insulin, usually as 70/30 NPH/regular, trade names Novolin N

Onset: 1-2h Peak: 6-14 h (most likely when hypoglycemic episode can occur) Duration: 16-24h

Rescue therapy for acute HA not responsive to NSAIDs and triptans

Opioids, antiemetics, short course of corticosteroids

Treatment of moderate acne

Oral abx with topical retinoid to start Once lesions controlled, can transition to topical antimicrobial with topical retinoid

Treatment of HSV-2

Oral acyclovir, famciclovir, valacyclovir

A teenager with moderate acne has not had sufficient response to benzoyl peroxide, topical retinoin, and topical antibiotics. What treatment option do you consider?

Oral antibiotics - doxycycline, minocycline, erythromycin, TMP/SMA, azithromycin Once skin is clear (usually after 3 months) taper off slowly over a few months while adding back topical antibiotic agents; rapid discontinuation results in return of acne to pretreatment baseline

Treatment for bacterial bronchitis

Oral macrolide or doxycycline

Management of mild to moderate dehydration

Oral rehydration solution, 50-100 ml/kg over 3-4 hours Best tolerated in frequent, small volumes Preferably supplied in office or urgent care setting to demonstrate ability to tolerate oral therapy

Transmission of HFM

Oral-fecal or droplet transmission Highly contagious with incubation of 2-6 weeks

A patient presents with an elevated TSH and NL free T4 (subclinical hypothyroidism). What is your best next step?

Order TPO antibodies and start on therapy if symptomatic/goiter on exam. Treatment with levothyroxine for patients with TSH>5 if there is a presence of a goiter or TPO antibodies, symptoms compatibly with hypothyroidism, infertility, pregnancy, or imminent pregnancy

A patient presents with a new onset thyroid nodule. How should you proceed?

Order TSH and thyroid u/s to determine size, location, characteristics If TSH suppressed (metabolically active lesion) - send for nuclear medicine thyroid scan to determine need for radioiodine ablation or surgery vs. fine-needle aspiration biopsy

Heberden's and bouchard's nodes are specific to what disease?

Osteoarthritis

Medicare D coverage

Prescription drug coverage Premium charged Must have part A and B

Treatment for moderate-to-severe otitis externa

Otic drops with ciprofloxacin/hydrocortisone Avoid neomycin containing products if punctured TM suspected

Pharmacologic actions of progestin

Ovarian and pituitary inhibition Thickening of cervical mucous Endometrial atrophy/transformation Cycle control

Pharmacologic actions of estrogen

Ovarian and pituitary inhibition Thinning of/increase in cervical mucus Endometrial proliferation Cycle control

Gram + abx

PCN Macrolides

You advise the parents of a well 6 month old that a mild fever of 1-2 days in duration is most likely to occur after the infant receives what vaccine?

PCV13

Treatment for malignant otitis externa in immunocompromise

PO ciprofloxacin in early disease or refer to ED for IV abx

Use of topical estrogen vs PO

PO for hot flashes and vasomotor symptoms Topical for atrophic vaginitis

Mild nonpurulent skin condition tx

PO penicillin VK, Keflex, dicloxacillin, clindamycin Impetigo only — mupirocin

A pregnant woman has been exposed to an individual with TB. What should you do?

PPD - valid and safe to use during pregnancy Untreated TB disease during pregnancy poses a greater risk to mom and baby as babies born to women with untreated TB disease may have low BW Pregnant women diagnosed with TB should be treated immediately. Antimicrobials should be carefully selected as some drugs are contraindicated during pregnancy

1st line GERD therapy

PPI Taken once a day prior to first meal of day for maximum effect Patients who do not respond to PPI should be referred for evaluation

Management of H. pylori infection

PPI BO BID + clarithromycin 500 BID + amoxicillin 1000 BID x 10-14 days (should not have previously received macrolide) OR PPI PO BID + clarithromycin 500 BID + Flagyl 500 BID x 10-14 days (penicillin allergic, should not have previously received macrolide) OR Bismuth subsalicylate 525 QID + Flagyl 250 QID + tetracycline 500 QID + ranitidine 150 BID (or) PPI BID x 10-14 d (for penicillin allergic) OR PPI + amox 1 g BID x 5 days followed by PPI BID + clarithromycin 500 + tinidazole 500 mg PO BID x 5 days (not preferred)

Management of lumbar spinal stenosis

PT NSAIDs Epidural corticosteroid injection Perhaps surgery

Long-term O2 therapy in COPD (indications to initiate)

PaO2 <55 mmHg or SaO2 <88 with or without hypercapnia PaO2 55-59 or SaO2 = 88 with pulmonary hypertension, peripheral edema, congestive cardiac failure, polycythemia (Hct >55) Goal: SaO2 >90% Always >15 h per day Venous vasodilator and reduces cardiac workload

S/s of osteoarthritis

Pain Tenderness Stiffness in the joint Reduced ROM and crepitus Erythema and warmth absent Effusion present

S/s of Osgood-Schlatter disease

Pain, swelling and tenderness in one or both knees that can vary from mild to debilitating X ray and PE used for daignosis

Open-angle glaucoma

Painless, gradual onset of increased intraocular pressure leading to optic atrophy Results in peripheral vision loss if untreated >80% of all glaucoma

Worrisome findings in an ill young child (toxic appearance)

Pale or cyanotic skin Poor cap refill Lethargic Weak or no cry Inconsolably irritable Tachypnea with resp rate >50% Tachycardia Unable to take or tolerate oral fluids, vomiting, dry mucous membranes, no evident of recent (within 4h), urinary output

Normal location of PMI

Palpable sensation of underlying LV 5th ICS, MCL Impulse is about size of a nickel Feels like gentle tap of a finger

Components of early prenatal care (1st visit)

Pap GC/chlamydia Rubella, varicella, rubeola Syphilis, HIV, HbsAg, HCV if at risk CBC Type and screen Screening for domestic violence, depression, substance use Update immunization status TST Genetic screening 1st trimester US, especially for unclear EDD UA Urine culture and sensitivity (treat asymptomatic bacteriuria) Update Td/Tdap if needed, MMR if not rubella immune, Hep B if needed, Var if not immune Flu vaccine 6-8 weeks

Diagnostics for suspected cervical cancer

Pap test followed by colposcopy and biopsy Pelvic CT and/or MRI or PET

Ddx for elevated PTH

Parathyroid hyperplasia Adenoma (benign) Malignant tumor

Most sedating SSRI

Paroxetine

What SSRI has the most anticholinergic effect?

Paroxetine

When to refer to burn center

Partial thickness burns that involve face, hands, feet, genitalia, perineum, major joints At risk populations Chemical burns Electrical burns Inhalational injury Partial thickness burns on more than 10% of body Third degree burns in any age group

1st line abx for exudative pharyngitis

Penicillin V PO x 10 days or benzathine penicillin IM x 1 dose

Who should receive TB screening?

People who have spent time with a TB-infected individual People from Latin America, Africa, Asia, Eastern Europe, Russia, Carribean People who live or work in a homeless shelter, long-term care facility, prison, nursing home Healthcare workers People with HIV infection People with symptoms of TB IVD users

Perceptual disturbances in delirium

Perceptual disturbances, including hallucinations

What visual change do you expect the patient to report with a dignosis of untreated open-angle glaucoma?

Peripheral vision loss "Silent thief of vision"

Treatment for scabies

Permethrin lotion

Most common cause of temporary speech delay in children?

Persistent OME

Diagnosis of venous insufficiency

Physical exam appearance of leg veins Duplex US can be used to assess blood flow ad limit other causes

Criteria for DM testing in asymptomatic adults

Physical inactivity 1st degree relative Members of high risk ethnic population Women who have given birth to a baby weighing >9 lb or were diagnosed with GDM HTN > 140/09 HDL cholesterol <35 or TG >250 Women with PCOS A1c >5.7, impaired glucose tolerance, or impaired fasting glucose Obesity Acanthosis nigricans CVD Age >45 and then q3y if normal results

Management of genital warts

Podofilox Liquid nitrogen Cryoprobe Trichloroacetic acid (acceptable in pregnancy) Bichloracetic acid Surgical removal Topical imiquimod (avoid use in pregnancy)

Occurrence basis professional liability insurance

Policy covers injuries that occur during the period the policy is active, regardless of whether the policy is renewed or continues to be in effect

Etiology of esophageal varices

Portal vein hypertension

L4 medications

Positive evidence of risk but may be used if maternal life threatening situation Lithium Ergot preparations Daily HD systemic corticosteroids >10 mg/kg/d long term

Complications of herpes zoster

Postherpetic neuralgia Opthalmologic involvement Superimposed bacterial infection

Aldosterone antagonist MOA

Potassium sparing diuretic Anti-androgen receptor sites Antagonism of these receptors inhibits sodium resorption in the collecting duct of the nephron in the kidneys.

Why should NSAIDs be avoided in the older adult? (Beer's criteria)

Potential to promote fluid retention and minimize effect of HTN medications (except CCB)

Drugs for low intensity statin therapy (not recommended)

Pravastatin 10-20 Lovastatin 20

To what populations do you not administer a live virus vaccine?

Pregnant women due to theoretical risk of passing virus to unborn child Immune suppression due to lack of clinical effect AIDS (CD4 <200)

Who should not take triptans?

Pregnant women, individuals with CVD and uncontrolled HTN because of vascular effect

Premeal insulin dosing for T2DM

Premeal glucose target is 70-130 If pre-lunch glucose >130, start 4 units bolus insulin before breakfast If pre-supper glucose >130, start 4 units bolus insulin before lunch OR add/increase morning NPH, detemir or glargine If bedtime glucose is >140, start 4 units bolus insulin before supper OR increase evening NPH, detemir, or glargine If not at goal, increase bolus insulin by 2 units every 3 days until insulin doses begin to exceed 10 units, then change dose by 10-20%

Tanner stage 1

Prepubertal for both males and females

IBS (irritable bowel syndrome)

Presence of altered GI motility and visceral hyperalgesia Microscopic inflammation with altered gut microflora as possible contributors

Sepsis

Presence of pathogenic organisms or their toxins in the blood and tissues with a resulting systemic inflammatory response

S/s of tertiary syphilis

Present variable, after primary and secondary symptoms have resolved

Most prevalent cancer in men

Prostate

What does an unusually forceful, sustained PMI indicate?

Pressure overload, HTN

Recommendation for Fe supplementation in preterm infants

Preterm infants receiving breast milk should receive 2 mg/kg/d of elemental iron through supplements or foods starting by age 1 month - 12 months

This term refers to the number of individuals in a population who have a condition at a given time

Prevalence

Management of Stage B HF

Prevent HF symptoms Prevent further cardiac remodeling ACE/ARB + BB In select patients... ICD, revascularization or valvular surgery as appropriate

Management of DM retinopathy with fluid leak or bleed, macular edema

Prevent disease progression with tight control of DM, HTN Photocoagulation Vitrectomy if disease progression contines to photocoagulation

Management of DM retinopathy without fluid leak or bleed

Prevent disease with tight DM, HTN control

Hx indicative of HF

Previous MI Angina HTN Valvular disease/rheumatic fever Palpitations

Low risk PNA individuals

Previously healthy No recent (<3m) systemic antimicrobial use

One of the most common causes of asymptomatic hypercalcemia in an otherwise well adult is...

Primary hyperparathyroidism

What is the most cost-effective form of healthcare?

Primary prevention

Best contraceptive options for smokers

Progestion only, DMPA, implant, IUD CU and LNG

You have a patient who presents with a red, painful eye and vision change. What are the appropriate next steps.

Prompt referral to ophthalmology

Medicaid

Provides medical benefits to low-income people who have no medical insurance or have inadequate medical insurance Varies state by state but implemented by the state Poverty alone not a qualifier Also blind, disabled, elder in need, child

What GI condition is caused by C. difficile infection

Pseudomembranous colitis No way for gut wall to reabsorb liquid

Common gram - organisms

Pseudomonas E. coli Gonorrhoeae Chlamydia

Common pathogens in otitis externa

Pseudomonas Other anaerobes S. Epidermidis S. Aureus (severe) Fungi, rarely

Management of postpartum depression

Psychotherapy Psychopharmacologic medication - will be secreted in breast milk Hospitalization for SI

Prenatal care 16-20 weeks

Quad marker/screen Ultrasound for fetal survey

Components of the nurse practice act

Qualifications for licensure Nursing titles that are allowed Scope of practice Actions that can or will happen if the nurse does not follow the nursing law

Grade 2 murmur

Quiet but immediately heard

Management of Osgood-Schlatter disease

RICE NSAIDs/tylenol Avoiding sports that involve heavy quadriceps loading or deep knee bending

Obturator sign

RLQ on internal rotation of right thigh indicative of appendicitis

Psoas sign

RLQ pain with extension of right thigh indicative of appendicitis

Management of cholecystitis

RUQ abdominal ultrasound Clear liquid diet May need to go to ED

What is the red cell distribution width (RDW)?

Range of sizes of RBCs NL 11.5-15% Abnormal >15% If >15%, new cells differ in size as compared to older cells. This is one of the earliest laboratory indicators of an evolving microcytic or macrocytic anemia. Quantification of "anisocytosis" As MCV increases, so does RDW

Adverse effects of DPP-4 inhibitors

Rare, well tolerated, good for older adults

Total T4

Rarely indicated Often altered in the absence of thyroid disease but with the use of exogenous estrogen, methadone, and in the presence of clinical conditions like pregnancy and chronic hepatitis

S/s of IBD

Rectal bleeding Diarrhea Fever Weight loss + CRP/ESR Leukocytosis during flares

Symptoms consistent with asthma

Recurrent cough Wheeze Shortness of breath and/or chest tightness due to variable airflow obstruction and bronchial hyperresponsiveness triggered by underlying airway inflammation Worse at night Worse with exercise Viral respiratory infections Allergens Pulmonary irritants

S/s of first degree burn

Red Painful Dry No blisters

Clinical triad of ophthalmologic emergency

Red eye Painful eye New onset vision change

S/s of second degree burn

Red, blistered, swollen, painful

Treatment of metabolic syndrome

Reduce LDL cholesterol with statins Increase HDL cholesterol with lifestyle modification Reduce BP through various agents Reduce blood sugar with standard oral diabetes medication or insulin injection ASAP to reduce risk of blood clots and stroke

Goals of asthma therapy

Reduce impairment Reduce risk of exacerbation or other complication Optimize health and function

Next step after a patient presents with ASCUS and high risk HPV + PAP

Refer for colposcopy

Examination of a 56 year old woman identifies a palpable thyroid mass of relatively fixed position. TSH is WNL. U/s reveals solid mass of approximately 5 cm in size. What is the next course of action?

Refer for fine needle aspiration biopsy

Treatment of severe acne

Refer to dermatology Oral antibiotic with topical retinoid If ineffective, accutane

A patient presents with elevated serum calcium and + 24 h urine calcium, and elevated serum PTH. You diagnose hyperparathyroidism. What is your anticipated plan of care?

Refer to endocrinology for consultation Surgery to remove problematic gland or lesion Cinacalcet — used to treat with CKD or parathyroid cancer Bisphosphonates in postmenopausal women to prevent osteoporosis In mild cases where surgery is not performed, avoid use of thiazide diuretics and lithium

Management of infantile communicating hydrocele

Refer to urology due to risk for herniation of abdominal contents

Treatment of chronic HBV infection

Regular monitoring for signs of liver disease progression Some patients treated with antivirals

Risk factors for senile cataracts

Risk factors: tobacco use, poor nutrition, sun exposrure, systemic corticosteroid therapy, aging

Prehn's sign

Relief of discomfort with scrotal elevation

Goals of COPD treatment

Relieve sxms Reduce frequency and severity of exacerbations

Therapeutic goals in treatment of mood disorders

Remission of symptoms for >4-5 months, aimed at the virtual elimination of a person's symptoms of depression or anxiety and restoration of his or her psychosocial and occupational functioning Consider longer-term therapy if >2 episodes Remission is most often achieved with a combination of therapies, including pharmacologic, psychologic, and social services

Level 4 99214

Requires 2 of 3 of the following Detailed hx Detailed exam Moderately complex medical decision making Ex. Established T2DM/hyperlipidemia, multisystem ROS, multisystem exam, plan to monitor glucose and BP, pharmacologic management, referring for consult

Level 3 visit 99213

Requires 2 of 3 of the following: Expanded problem focused hx Expanded problem focused exam Low clinical decision making Ex. + ROS, Exam ENT/abdomen; RST +, rx amoxicillin

Level 2 visit 99212

Requires 2 of 3 of the following: Problem focused hx Problem focused exam Straightforward medical decision making Ex. ENT exam only/URI with symptomatic therapy

Level 5 99215

Requires 2 out of 3 of the following: Comprehensive hx, comprehensive exam, highly complex medical decision making Ex. CHF/CKD/HTN with new onset dyspnea; detailed hx and exam with multisystems included; evaluating efficacy of current treatment plan for potentially life-threatening multisystem condition, possible hospitalization

Higher risk PNA patient characteristics

Risk for atypical pathogens Comorbidities like COPD, diabetes, renal or heart failure, asplenia, alcoholism, immunosuppressing conditions, malignancy or use of systemic abx in last 3 months

Primary skin lesion

Result from a disease process Has not be altered by outside manipulation, treatment, etc. Ex. Herpes zoster

Secondary hyperparathyroidism

Result of another condition like chronic renal faliure, calcium or vitamin D deficiency that lowers serum calcium levels, resulting in parathyroid glands over prodcing PTH

Paraphimosis

Retracted foreskin that cannot be brought forward to cover the glans

Orthopedic ddx in the patient with systemic signs and symptoms

Rheumatoid arthritis SLE Polymyalgia rheumatica

What antibiotics are most likely to reduce the effectiveness of oral contraception?

Rifampin Causes progestin and estrogen to both be offloaded This does not extend to IUD/IUS

Why should you send an immunocompromised person with malignant otitis externa to the ED?

Risk for osteomyelitis of the skull or TMJ MRI or CT imaging to r/o osteomyelitis often indicated ENT consult with surgical debridement Obtain cultures of ear drainage or results of surgical debridement Prenteral antimicorbial therapy often warranted for severe disease

What is the major risk associated with fifth's disease and the pregnant woman

Risk of hydrops fetalis with resulting pregnancy loss when contracted by women during pregnancy

What characteristics are most consistent with a malignant thyroid nodule?

Risk that a thyroid nodule is malignant = about 5% Hx of head or neck irradiation Size > 4cm Firmness Nontender Relatively fixed position Persistent nontender cervical lymphadenopathy Dysphonia Hemoptysis

DDx for derm condition in an otherwise well patient without systemic symptoms

Rosacea Keratosis pilaris Seborrheic dermatitis

Anal cancer testing recommendations (Pap)

Routine testing not recommended in asymptomatic men or women Test HIV+, those who receive anal sex, hx of anal warts Women with hx of cervical or vulvar cancer No consensus agreement on frequency of testing, but consider every year for HIV+, and 2-3 years for HIV-

Most common cause of subarachnoid hemorrhage

Ruptured cerebral aneurysms

Common pathogens in suppurative conjunctivitis

S. Aureus S. Pneumoniae H. Influenzae Some s. Pneumoniae outbreaks (resistant to tobramycin, gentamicin)

Most common bacterial pathogen in ABRS, AOM, and CAP

S. Pneumoniae Gram + diplodocus, causes 38% ABRS in adults ~25% are drug resistant via altered protein binding sites

Causative pathogens of CAP

S. pneumoniae (Gram + diplococci) M. pneumoniaie (atypical) C. pneumoniae (atypical) Respiratory viruses RSV Adenovirus Parainfluenza Legionella, H. influenzae require short-term inpatient stay

Likely causative pathogens in low risk PNA

S. pneumoniae (Gram +) with low DRSP risk, little risk of H. influenzae Atypical M. and C. pneumoniae Viruses

Likely causitive organisms in higher risk individuals for PNA

S. pneumoniae (gram +) with DRSP risk H. influenzae (gram - ) Atypical pathogens (M. pneumoniae, C. pneumoniae, legionella)

Causative organisms in acute bacterial otitis media

S. pneumoniae, H. influenzae, M. catarrhalis (will get better without abx)

Pathogen associated with scarlet fever

S. pyogenes group A beta hemolytic streptococci

Fibric acid derivative MOA

Seldom indicated Increases HDL Decreases TG

Criteria for obtaining an MRI for LBP

S/s of radiculopathy that persist after trial or standard conservative therapy in patients who are candidates for surgery or epidural corticosteroid injection Risk factors for or symptoms of spinal stenosis in patients who are candidates for surgery >1-2 months of conservative therapy

What heart sounds do you expect to hear in HF

S3 Murmur

Medications for COPD

SABA for bronchospasm (PRN) LABA (salmeterol, used daily) LAMA (titropium bromide, minimizes risk of COPD exacerbation, used daily) ICS (minimizes risk of COPD exacerbation, used daily) Theophylline (bronchildilator, PO, used daily) PDE-4 inhibitor (roflumilast, oral, used daily)

Medication management in COPD exacerbation

SABA or SAMA PRN + LABA/LAMA if not currently using Systemic corticosteroids like prednisone 40 x 5 d Smoking cessation May need 5-7 days of antimicrobials **ALWAYS A SYSTEMIC CORTICOSTEROID, RARELY AN ABX**

Medications for Patient Group A COPD (low risk, less sxms) GOLD 1-2

SAMA (ipratropium bromide) or SABA PRN

Beta-1 selective beta blockers

Safer in patients with COPD, asthma, DM, peripheral vascular disease Metoprolol Bisoprolol Betaxolol Acebutolol

Drugs associated with Reye's syndrome in children contain what?

Salicylate (Pepto, ASA)

Symptomatic treatment for ABRS

Saline nasal irrigation's Intranasal corticosteroids when ABRS is accompanied by allergic rhinitis Most people will get better without an antibiotic

S/s of scarlet fever

Sandpaper rash with exudative pharyngitis Fever HA Tender, localized anterior cervical lymphadenopathy Rash usually erupts on day 2 of pharyngitis and often peels a few days later

DDx for derm condition in a highly symptomatic but not systemically ill patient

Scabies Shingles Eczema Urticaria

Discharge noted in genitourinary syndrome of menopause AKA atrophic vaginitis

Scant White-clear

Managment of the woman with gestational diabetes 6-12 weeks postpartum

Screen for DM with a test other than A1c Ongoing counseling to avoid the development of T2DM should be offered and encouraged if postpartum glucose WNL If not, treat as T2DM

Prenatal care 24-28

Screen for gestation DM with 2h GTT (screen earlier with BMI >30) RH neg - type and screen (Rhogam if needed)

Markers of Hep C infection

Screening assay for + anti-HCV Verification by HCV RNA Normal to slightly elevated hepatic enzymes

Acute bacterial rhinosinusitis

Secondary bacterial infection of paranasal sinuses, usually following viral URI

Management of acute pancreatitis

Send to ED for pain management and gut rest

Dizziness

Sense of disturbed relationship to space, but surroundings not moving Multiple causes including circulatory (orthostatic hypotension), neurologic (Parkinson's), medications, anxiety, hypoglycemia, dehydration

This term refers to the ability of a test to correctly indentify those who HAVE a condition

Sensitivity

What lab should you obtain when you are concerned about rubella and/or rubeola?

Serum Rubella IgM and serum rubeola IgM

Sequalae of Hep D infection

Severe infection Hepatic failure Death

Causes of transmission of Hep B

Sexual contact Blood Body fluids Birth to an infected mother

You have a 55 year old patient who has longstanding myopia and presbyopia, both corrected with eyeglasses. She is normotensive without complaint. What do you expect to find on ocular exam.

Sharp disc margins Arterioles that are brighter and narrower than the vein

S/s of lumbar radiculopathy

Sharp, burning, electric shock sensation Worse when increased spinal fluid pressure Sneezing, cough, straining evokes sharp pain Signs of LS strain Altered neuro exam including abnormal straight leg raise, sensory loss, altered DTRs

DPP-4 inhibitor example and MOA

Sitagliptin (Januvia), other -gliptins Insulin release post glucose rise

S/s of moderate dehydration (6-9%)

Skin turgor <2 s recoil Fontanels slightly depressed Dry lips and oral mucosa Tears decreased Eyes slightly sunken Cap refill 1.5-3 s Decreased urine output Increased thirst Mental status fatigued, restless, irritable

S/s of severe dehydration (>10%)

Skin turgor >2 s recoil with tenting Depresed fontanels Very dry lips and oral mucosa Deeply sunken eyes Tears absent Cap refill >3 seconds Apathetic, lethargic, or unconscious No urine output/minimal Very thirsty or too lethargic to assess

L2 medications

Smaller # of women studied w/o risk Macrolide abx Nitrofurantoin Cephalosporins 2nd gen antihistamines Prednisone SSRIs

Risk factors for PAD

Smoking Age DM HTN Hypercholesterolemia

Non-pharmacologic treatment for COPD

Smoking cessation Physical activity Flu/pneumo vaccine Pulmonary rehab

Management of PAD

Smoking cessation Physical activity Weight loss Control BP, cholesterol, BG ASA 81 Cilostazol and pentoxifylline can reduce sxms Surgery to improve blood flow Refer to vascular

Conductive hearing loss

Sound blocked by ear wax, foreign object, damaged eardrum, serous otitis media, otitis media with effusion, bone abnormality Weber: Sound lateralizes to affected ear Rhine test: Bone conduction > air conduction Treat with cerulean impaction removal, URI/AOM resolution

Potential dietary triggers influencing the onset or severity of migraine or other primary HA symptoms

Sour cream Ripened cheeses Sausage Pizza Chicken liver/pate Herring Pickled, dried, marinated food MSG Yeast products Chocolate Nuts Beans Onions Dried fruits Citrus fruits Bananas Caffeine Alcoholic beverages Aspartame/phenylalanine containing foods or beverages

S/s of lumbar-sacral sprain

Spasm, ache, stiffness Position, activity, rest typically impacts pain Normal neuro exam Paraspinal muscle tenderness and spasm LS curve straightening Decreased flexion

2 year old developmental milestones

Speaks in 2 word sentences Follows 2 step commands Builds a 2 block tower with ease and up to a 4 block tower Can walk up to 2nd floor with help Copies others Shows defiant behavior Plays alongside other children Points to things when they are named Sorts shapes and colors Stands on tiptoe Kicks ball Begins to run Climbs onto and down from furniture without help Walks up and down stairs Throws ball overhand

4 year old developmental milestones

Speaks in 4 word sentences Can build a 4 block tower with ease Can draw a cross

"Incident to" billing

Specific to medicare Allows 100% reimbursement at MD rate where the NP must be employed by the MD MD must be present/available in the office MD initiates treatment Services provided by NP are under MD supervision

This term refers to the ability of a test to correctly identify those who DO NOT HAVE a condition

Specificity

Modifiable hot flash triggers

Spicy foods Chocolate EtOH Elevated ambient temperature and humidity Tight, restrictive clothing Cigarette smoking Hot baths Relaxation techniques

What is required for COPD diagnosis?

Spirometry FEV1:FVC < 0.7 post bronchodilator Classification of severity determined by FEV1

What is needed to make the diagnosis of asthma?

Spirometry Objective evaluation with FEV1 or peak expiratory flow rate for airflow obstruction should be conducted with every asthma-related visit Asthmatics will have increase from FEV1>12% from baseline post SABA use - airflow obstruction is partially reversible

Aldosterone antagonist example

Spironolactone, eplerenone

Are squamous cell carcinoma or basal cell carcinoma more likely to be metastatic?

Squamous cell

Actinic keratoses have a 1% chance of turning into what cancer

Squamous cell carcinoma

At what stage of HF should routine use of diuretics be considered?

Stage C

12 month old developmental milestones

Stands tall like the #1 (12-15 months) Walks on 2 legs Stranger anxiety Hands you a book when he wants to hear a story Repeats sounds or actions to get attention Helps with dressing Responds to 1 stage requests Says "mama" and "dada" and "uhoh" Gets to a sitting position without help Pulls to stand, cruises May take a few steps without holding on May stand alone

Common gram + organisms

Staph Syphillis Strep

When would you see AV nicking on ocular exam?

Stiffened, thickened arterioles seen with chronic HTN

Most common musical or vibratory murmur

Still murmur

Angle-closure glaucoma

Sudden increase in intraocular pressure Usually unilateral, acutely red, painful eye with visual change including halos around lights Eyeball is firm when compared to other *Emergency*

How can you prevent positional plagiocephaly?

Supervised, awake "tummy time" Start immediately post-birth, building up slowly to a total of 30 minutes per day until such time as child easily turns tummy-to-back, back-to-tummy without assistance (usually around 6 months)

Medicare B coverage

Supplemental insurance covers outpatient services NP can be reimbursed for "physician-like" services

Treatment of acute HBV infection

Supportive care

Treatment of acute HAV infection

Supportive care Liver transplantation as an option in select cases of fulminant hepatitis failure -- rare Low mortality rate

Hyperthyroidism clinical presentation: "Sweating"

Sweating Weight loss ~10 lb. Emotional lability, "mind racing," memory alteration Appetite increased Tremor/tachycardia Intolerance of heat, irregular menstruation, irritability Nervousness Goiter/GI problems (frequent, low volume, loose stools)

Classification of osteoporosis

T score below -2.5 BMD is 2.5 SD below that of a young normal adult Patients in this group who have already experienced one or more fractures are deemed to have severe or established osteoporosis

Is mitral valve prolapse systolic or diastolic?

Systolic Mr. Pass wins the MVP

The most common form of new onset HTN in the older adult

Systolic HTN "Pipes are getting stiffer" - increased PVR

Hemic murmur

Systolic ejection murmur commonly found in marked anemia Also found in profound dehydration, thyrotoxicosis, third trimester of pregnancy, and high fever

Possible etiologies for HF

Systolic left ventricular (LV) dysfunction (most frequent cause of HF) Diastolic LV dysfunction Valvular disease Congenital heart disease Pericardial disease Endocarial disease Rhythm/conduction disturbance

Are systolic murmurs benign or pathologic? Diastolic?

Systolic murmurs can be either Diastolic murmurs are always pathologic

Clinical exam findings in HF

Tachycardia JVP distention Displaced apex beat S3 heart sound Murmur Pulmonary crackles Dependent edema

The absence of what is the most use clinical finding for ruling out pneumonia in children and elders?

Tachypnea

PE findings in PNA

Tachypnea (impaired resp. rate due to impaired gas exchange) Crackles or rales (occurs with sudden opening of distal fluid-filled airways - may have improvement with cough) Consolidation (dullness to percussion and increased tactile fremitus) Pleuritic friction rub (caused by pleural inflammation, patient report of sharp, localized pain, worse with deep breath, movement, cough

Recommendation for Fe supplementation for term infants

Taking more than 1/2 feedings as human milk should receive 1 mg/kg/d of supplemental iron starting at age 4 months until the introduction of complementary foods

Physiologic gynecomastia is usually found in what tanner stage?

Tanner stage 3

Basal insulin dosing for T2DM

Target FPG 70-130 HS basal insulin: 10 units or 0.2 units/kg --> increase dose 2 units every 3 days until FPG is 70-130; can increase by 4 units every 3 days if FPG is >180

Sequalae of metabolic syndrome

Target organ damage including heart disease, diabetes, renal dysfunction and stroke

How should you treat A1c not at goal for T2DM if AC and HS insulin has been optimized?

Target postprandial glucose with bolus premeal insulin

Clinical presentation of giant cell arteritis

Tender or nodular pulseless vessel (usually temporal artery) accompanied by severe unilateral headache 50% will experience visual impairment, including transient visual blurring, diplopia, eye pain, sudden loss of vision CRP, ESR markedly elevated

Physical exam findings in prostatitis vs. prostate cancer

Tender, boggy, indurated, as firm as pressing over cheekbone vs. nodular, firm, nontender, malignant lesions not palpable until advanced

Cryptorchidism

Testicle located in inguinal canal or abdomen, undescended

Schedule III drugs

Testosterone Butalbitol

Abx with gram + and gram - coverage

Tetracycline Cephalosporin Fluoroquinolone Sulfonamides Carbapenems Nitrofurans Metronidazole (also for anaerobes)

Cooley's anemia

Thalassemia major - people of Mediterranean descent - defect in hemoglobin.

Competency in healthcare decision making

The ability to exercise rights, more in particular, the ability to exercise one's right to give or refuse informed consent

Hantavirus Pulmonary Syndrome (HPS)

The causative agent is the hantavirus, part of the viral family known as Bunyaviridae. May be transmitted when aerosolized (airborne) urine and droppings from infected rodents are inhaled. Primary vectors are four species of rodents: cotton rat, rice rat, white-footed mouse, and deer mouse.

Where is the child placed for "time-out"?

The child sits in a special place that is safe, easily observed by parent or caregiver, uninteresting, and is only used for time out. Avoid the use of bed, bedroom, or any place where the child could be frightened.

Reliability

The concept that results can be repeated and are not just a fluke Ex. a depression scale must repeatedly support depression in a depressed patient to be reliable

Spurling test

The examiner turns the patient's head to the affected side while extending and applying downward pressure to the top of the patient's head. To assess for cervical nerve root compression

Veracity

The healthcare provider must be truthful and avoid deception

Sxms of shock

The main symptom of shock is low blood pressure. Other symptoms include rapid, shallow breathing; cold, clammy skin; rapid, weak pulse; dizziness, fainting, or weakness.

Management of ectopic pregnancy

The majority of ectopic pregnancies resolve without intervention, but if the fallopian tube tears and tears the ovarian artery, it can be life threatening Salpingostomy Salpingectomy Methotrexate if theconceptus is <3.5 cm with no evidence of cardiac activity; unruptured tube, hCG <15,000, hemodynamically stable, available for close f/u

pernicious anemia

The most common cause of pernicious anemia is the loss of stomach cells that make intrinsic factor. Intrinsic factor helps the body absorb vitamin B12 in the intestine. Autoimmune, commonly found in older women

Beneficience

The obligation of the healthcare provider to help those in need

Relative risk reduction

The percentage of risk removed by the treatment Control group %-treatment group%/control group%

Culture

The totality of socially trasnmissed behavioral patterns, arts, beliefs, institutions, and all other products of human work and thought; an integrated pattern of human thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group

Initial antihypertensive drug choice for black, no CKD

Thiazide or CCB

Concomitant conditions that make it difficulty to palpate PMI

Thick chest wall Obesity COPD

S/s of third degree burn

Thickened, hypopigmented

Age related maculopathy (macular degeneration)

Thickening, sclerotic changes in retinal basement membrane complex resulting in painless distortion of central vision. On fundoscopic exam, soft yellow deposits on the macular region (drusen) are visible Can be "dry" or "wet"

Discharge in BV

Thin Homogenous White Gray Adherent Often increased Foul odor "whiff test"

You examine a healthy 2 month old boy and note that his foreskin cannot be retracted. You consider that...

This is a normal finding The foreskin is not easily retractable until the child is about 3 years old Only concerned if ballooning of the foreskin

Moro reflex

Throwing out arms and legs followed by pulling them back to the body, following a sudden movement or loud noise. No longer seen by 16 weeks.

Drop arm test

To assess for rotator cuff injury Abduct the arm out to 90 degrees then ask the patient to adduct arm slowly Full thickness rotator cuff tear will not be able to do this

Management of in genitourinary syndrome of menopause AKA atrophic vaginitis

Topical and/or vaginal estrogen if symptomatic and/or recurrent UTI Oral estrogen as solo intervention likely inadequate

3rd line acne medication

Topical antibiotics like clindamycin, erythromycin, dapsone Most effective for mile acne

1st line acne medication

Topical benzoyl peroxide

Treatment of urushiol-induced contact dermatitis

Topical for localized acute contact dermatitis with triamcinolone 0.1% ointment If >20% BSA affected, give prednisone 0.5 -1 mg/kg/day for 5-7 days Tota l recommended systemic corticosteroid therapy duration 10-14 days No additional taper if <14 days Calamine lotion to help itching and oral antihistamines

Treatment for tinea pedis

Topical ketoconazole

Management of genital candidiasis in men

Topical miconazole Obtain in-office blood glucose Do not recommend anti-microbial soap

Treatment of open-angle glaucoma

Topical miotics, beta-blockers Surgery

Treatment of mild acne

Topical retinoid alone often helpful, consider topical abx or benzoyl peroxide

2nd line acne medication

Topical retinoids like tretinoin gel Keratolytic, signfiicant antiinflammatory effect Photosensitizing

Estrogen therapy for women with a hx of breast cancer

Topical/vaginal estrogens with a dose of <25 estrodiol BID is safe

When evaluating a patient for a potential thyroid disorder, what is the least informative test from the thyroid panel?

Total T4

How is varicella transmitted?

Transmitted person-to-person by direct contact, inhalation of aerosols from vesicular fluid of skin lesions of acute varicella, or aerosolized respiratory tract secretions

Diagnostics for suspected endometrial cancer

Transvaginal US Hysteroscopy Endometrial biopsy Fractional dilation and curettage

Confirmation of intrauterine pregnancy

Transvaginal US: Gestational sac in normal IUP when hCG >1,000 Transabdominal US: Gestational sac in normal IUP hCG >6,500

Who is at risk for Hep A?

Travelers to regions with intermediate or high rates of HepA Sex contacts with infected persons Household members or caregivers of infected persons MSM IVDU Persons with clotting-factor disorders

What TCA has no anticholinergic effect?

Trazodone

Abortive medication for migraine

Triptans (Selective serotonin receptor agonists - sumatriptan, almotriptan, razatriptan), some ergot derivatives

Who should be treated for osteoporosis/osteopenia?

Tscore <-2.5 at femoral neck, total hip, or spine Postmenopausal women/men>50 with osteopenia and + FRAX score

Possible sequalae of PID

Tubal scarring Increased risk for ectopic pregnancy and/or infertility

Causes of secondary headache

Tumor Intracranial bleeding Increased ICP Nitrate use Meningitis Accelerated hypertension Giant cell arteritis Viremia (usually self resolving)

Rooting reflex

Turning of head and sucking when cheek is stroked. No longer seen by 6-12 months.

A patient presents with difficulty swallowing and microcytic hypochromic anemia. What study do you refer him for?

Upper endoscopy

Epididymoorchitis

Upper reproductive tract infection with inflammation of epididymis/testis Male equivalent of PID In men <35, most frequently G/C

Prenatal care 41+ weeks

Typically labor induction at 41 weeks Non stress test Biophysical profile to check fetal status

Diagnostics to always order in the older adult with new onset altered mental status

UA UC & S Electrolytes, esp. Na and Ca BUN, Cr Glucose Hepatic enzymes Vitamin B12/folate TSH RPR/VDRL (for neurosyphilis) CBC with WBC diff EKG

1st trimester combined testing for trisomy 21

US measuring nuchal translucency/gestational age + seru pregnancy associated plasma protein, beta hCG

When should you screen for TSH?

USPSTF - Level I recommendation American Thyroid Association recommends TSH every 5 years for individuals > 35

Where is the uterine fundus at 20 weeks

Umbilicus

8-9 month developmental warning signs

Unable to bear weight on legs with support Unable to sit with help Doesn't babble ("mama," "baba") Doesn't play any games involving back-and-forth play Doesn't respond to own name Doesn't seem to recognize familiar people Doesn't look where you point Doesn't transfer toys from one hand to another

Free T4 (free thyroxine)

Unbound, metabolically active portion of T4 Follow up test to confirm diagnosis in face of abnormal TSH About 0.025% of all T4 NL = 10-27

Free T3

Unbound, metabolically active portion of triiodothyronine (T3) 4x as metabolically active as T4 About 20% is from thyroid, the rest is transformed from T4

Absolute contraindications to estrogen replacement therapy

Unexplained vaginal bleeding Acute liver disease Chronic impaired liver function Thrombotic disease Neuro-opthalmologic vascular disease Endometrial cancer Breast cancer Caution: seizure disorder, hypertriglyceridemia

Symptoms of ACS in women

Unusual fatigue (70%) Weakness (55%) Unusual fatigue during the event (43%) Diaphoresis or cold sweat (39%) Dizziness (39%) Chest pressure or pain (30%) No chest discomfort during event (30%

What is the substane associated with phytodermatits (pooison ivy, poison oak, popison sumac)

Urushiol

Onset of action, peak, duration for rapid acting insulin

Used at meal time or as correction Onset: 15 minutes Peak: 1 h (most likely when hypoglycemic episode can occur) Duration: 4h

CURB-65 score

Used to calculate the location of appropriate treatment for a person with CAP. Each item carries a weight of 1 point. The higher the score, the greater risk of CAP-associated mortality. C = confusion of new onset U = Blood urea nitrogen > 19 R = Respiratory rate > 30 bpm B = Blood pressure > 90 systolic or 60 diastolic 65 = Age >65 0-1 = Treat as otpt with PO 2 = Consider short stay in hospital or watch very closely as outpatient. Oral or parenteral abx as dictated by disease severity, GI function, care setting. 3-5 = Requires hospitalization with consideration as to whether patient needs ICU

EDD by 2nd trimester u/s (up to 22 weeks)

Uses biparietal diameter, femur length, etc. Accurate with potential of 10-14 day error

EDD by 1st trimester u/s

Using crown-rump measurement, accurate with potential of 7 day error margin (most accurate)

Grade 4 hypertensive retinopathy (high grade)

Usually DBP >130 mmHg, implies HTN emergency Papilledema with preceding signs (too much pressure in the brain) Potential for visual change and permanent findings

Psychomotor changes in delirium

Usually a change, either hyperkinetic (25%), hypoactive (25%), or mixed (35%). No change in 15%

S/s of rubeola/measles

Usually acute presentation with fever, nasal discharge, cough, generalized lymphadenopathy, conjunctivitis with copious clear discharge, photophobia, Koplik spots, mild pharyngitis without exudate, maculopapular drash 3-4 days after onset of symptoms, may coalesce to generalized erythema

Grade 3 Hypertensive retinopathy (high grade)

Usually with DBP >110 mmHg, implies HTN emergency Preceding signs with flamed shaped hemorrhages Potential for visual change and permanent findings Visual complaint: black spots in visual field

Why does the fundal height drop at term?

Uterus dips into pelvis with fetal head engagement

Prenatal care 40-42 weeks

Vaginal exam to assess cervical ripeness, fetal station

Management of stress incontinence

Vaginal tampon Urethral stents Periurethral bulking agent injections Pessary Kegel exercises Pelvic floor rehab with biofeedback Surgical intervention rarely

How is zoster transmitted?

Varicella virus possibly transmitted person-to-person by direct contact, inhalation of aerosols from vesicular fluid of zoster lesions

Grade 1 murmur

Very faint Usually not of clinical consequence

Grade VI murmur

Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible

Grade V murmur

Very loud, with thrill. May be heard when the stethoscope is partly off the chest

Treatment for secondary hyperparathyroidism

Vitamin D supplementation Phosphate binders Calcimimetics (cinacalcet) Surgery if medical therapy fails Ensure adequate amount of calcium and vitamin D intake Surgery only considered if medical therapy fails

Management of mild-to-moderate stage disease in AD

Vitamin E 1,000 IU BID Cholinesterase inhibitors (donepezil/Aricept, rivastigmine/exelon) have time-limited benefits by increasing the availability of acetylcholine

What supplement should be used to slow the decline in AD?

Vitamin E 1,000 IU BID or elegiline 5 mg BID (no added benefit to using both)

Stepping reflex

Walking motion made with legs and feet when help upright and feet touching the ground. Appears for first 3-4 months, then reappears at 12-24 months.

Highly protein bound drugs

Warfarin 99% albumin bound Pheyntoin Valproic acid Diazepam

Reassuring findings in an ill young child (<3 years)

Warm Dry Pink Brisk cap refill <2s Regards parental face, clings to parent, consolable, age-appropriately resists exam Lusty cry Smiling, interactive as appropriate Resp rate <50% HR WNL, adjusted for fever Tolerates oral fluids without vomiting, adequately wet diapers "a smiling child is seldom septic"

With poor renal function, people waste ______ and spare ______? (Electrolytes)

Waste sodium and spare potassium

How can you treat acanthosis nigricans?

Weight loss

Management of venous insufficiency

Weight loss Physical activity Compression stockings Refluxing superficial vessels through sclerotherapy or ablation

Treatment of osteoarthritis

Weight loss Strengthening Low-impact aerobic exercise Neuromusclar education

Non-pharmacological management of GERD

Weight loss for those who are overweight or obese Head of bead elevation Avoidance of meals 2-3h before bedtime Avoid chocolate, caffeine, alcohol, acidic foods if they trigger symptoms

Lifestyle modification recommendations in HTN and dyslipidemia

Weight reduction in overweight obesity DASH eating plan Dietary sodium reduction Aerobic physical activity for hypertension and dyslipidemia (40 minutes/d x 4 days per week, no more than 48h without exercise) Moderation of alcohol consumption (<2 drinks/d for men, <1 drink/d for women)

Visit frequency for well-controlled asthma vs. not well-controlled asthma

Well controlled: 3-6 months Not well controlled: 2-6 weeks Try to get patient in to see you September-October for flu shot and need for controller meds

Questions to ask prior to choosing an antimicrobial

What is the most likely pathogen causing this infection? What is the spectrum of a given antimicrobial's activity? What is the likelihood of a resistant pathogen? What is the danger if there is treatment failure? What is the optimal safe antimicrobial dose? What is the duration of the shortest but still effective therapy?

When do you refer a patient with HF to cardiology?

When structural heart disease is diagnosed Patient does not need to have s/s of HF e.g. patients with previous MI, LV remodeling including LVH and low EF, asymptomatic valvular disease

When should you obtain a contrast CT of paranasal sinuses and/or MRI with contrast for ABRS

When the child is suspected of having orbital or CNS complications

Ideal treatment in higher DRSP CAP treatment or risk for atypical organism

When the gut works (not when vomiting), IV abx are not more advantageous over PO Moxifloxacin or levofloxicin OR doxycycline, azithromycin or clarithromycin + beta lactam

S/s of herpes simplex virus infection

With initial infection, classic presentation of painful ulcerated lesions, marked lymphadenopathy In women, thin vaginal discharge if lesion located at vagina or introitus With recurrence, symptoms vary Asymptomatic transmission common

When should you expect neonatal breast engorgement to resolve?

Within first 2 months of life This is present in 5% of all healthy newborns

Post partum "baby blues"

Within in days of giving birth, 80% resolve by week 2 Characterized by emotional lability, sleep disturbance, difficulty concentrating If persists beyond 2 weeks, consider PPD as diagnosis

Discharge in candida vulvovaginitis

White Curdy "Cottage cheese" like

Koplik spots

White spots with blue rings held within red spots in oral mucosa Appear ~2 days prior to onset of measles rash

S/S of candida vulvovaginitis

White, Curdy, "Cottage cheese" like discharge Itching Burning

Physiologic discharge

White, clear, flocculent (physiologic leukorrhea)

Sxms of hypoglycemia

Whole body: excess sweating, excessive hunger, fainting, fatigue, lightheadedness, or shakiness Gastrointestinal: nausea or vomiting Cognitive: mental confusion or unresponsiveness Mouth: dryness or tingling lips Also common: anxiety, blurred vision, headache, irritability, pallor, palpitations, sensation of pins and needles, sleepiness, slurred speech, tremor, or unsteadiness

LDL reduction with low intensity statin therapy

Will reduce by 30% No recommendation for low intensity statins

LDL reduction with medium intensity statin therapy

Will reduce by 30-49%

LDL reduction with high intensity statin therapy

Will reduce by >50%

When should you measure visual acuity?

With ANY eye complaint

Folic acid requirements in pregnancy

Without hx of neural tube defect, 0.4-1 mg/d With FHx of neural tube defect, 4 mg/day for 1 month before pregnancy and during first 3 months gestation, then resume 0.4-1 mg/d in order to promote placental and fetal growth

Patient presentation of DM retinopathy without fluid leak or bleed

Without vision complaint Detected on dilated eye exam

ARBS diagnosis in children

Worsening URI course, such as double sickening, defined as acute worsening of resp symptoms or new fever at day 6-7 of URI Persistence of URI like symptoms without improvement after 7-10 days, including nasal discharge, daytime cough, bad breath, fatigue, HA, decreased appetite Acute onset T >102.2F, purulent nasal discharge, ill appearance for 3-4 days

Diagnosis of osteoarthritis

X ray shows narrowing of joint space, changes in bone, presence of bone spurs (osteophytes)

Turner syndrome

X,O female Characterized by short stature, wide, webbed neck, shield shaped chest High rate of spontaneous abortion

Klinefelter syndrome

XXY male Low testicular volume, hip and breast enlargement, infertility Does not make sperm

Can individuals with chronic HepB transmit to a sex partner?

Yes

Schedule IV drugs

Zolpidem Benzodiazepines Phentermine

Amsler grid test

a central field of vision test that is a subjective monocular grid test designed to evaluate the function of the retina in the macular area of each eye, which is where 20/20 vision occurs For evaluation of macular degeneration

Presbycusis

age related hearing loss Usually exacerbated by ambient noise

Lachman test

application of anterior and posterior force to the proximal posterior tibia to determine the stability of the ACL and PCL

cholecystitis vs cholelithiasis

cholecysttitis: acute inflammation + gallstones cholelithiasis: gallstones alone

McMurray Test

compression of the meniscus of the knee combined with internal and external rotation while the patient is face-up to assess the integrity of the meniscus

Febrile seizure

convulsions brought on by a fever in infants or small children. During a febrile seizure, a child often loses consciousness and shakes, moving limbs on both sides of the body.

What is pancytopenia?

deficiency of all three cellular components of the blood (red cells, white cells, and platelets). Must investigate if bone marrow is producing hemocytoblasts

Telengiectasia

dilated superficial blood vessels

Rhabdomyolysis

dissolution of striated muscle (caused by trauma, extreme exertion, or drug toxicity; in severe cases renal failure can result)

SSRI with the least DDI potential

escitalopram

Zygote

fertilized egg

Phimosis

foreskin is advanced and tightly fixed over the glans penis

polymyalgia rheumatica

geriatric inflammatory disorder of the muscles and joints characterized by pain and stiffness in the neck, shoulders, upper arms, and hips and thighs R/t giant cell arteritis

myositis

inflammation of muscle tissue

Talar Tilt Test

inversion of the foot to determine the stability of the ankle joint

Risk factors for ovarian cancer

late first parity, low parity, early menarche, late menopause, endometriosis, HRT > 5 yr, FH, BRCA mutation, high fat diet Has shared etiology with breast cancer Use of estrogen post menopause Some fertility drugs

Metatarsus adductus

most common deformity of the foot, marked by the middle bones of the foot pointing in toward the body Very common in early walkers "Pigeon toed"

Papilledema

optic disc swelling that is caused by increased intracranial pressure

Murphy's sign

pain with palpation of the RUQ during inspiration, indicative of cholecystitis (palpation of the gallbladder)

How frequently should you obtain A1c for patients who are meeting treatment goals and who have stable glycemic control? Not meeting goals?

q6m; q3m

Blumberg's sign

rebound tenderness

Blastocyst

stage of early development in mammals that consists of a hollow ball of cells First 2 weeks Ball of undifferentiated cells

Urge incontinence

state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void

Schedule I drugs include

substances that have no accepted medical use and a high potential for abuse Heroin, MDMA, PCP

Stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

Null hypothesis

there is no relationship between the variables

Treatment for rosacea

topical metronidazole

Testicular torsion

twisting of the spermatic cord causing decreased blood flow to the testis Characterized by scrotal pain and loss of the cremasteric reflex Phren's sign negative

S/s of cluster HA

unilateral, excruciating, steady pain in eye or temple ipsilateral nasal congestion, ptosis, face swelling very frequent Occurs at characteristic times of year like vernal and autumanl equinox with 1-8 episodes per day at the same time per day Male: female ratio 3:1 FHx present in 20%