PC Illness Women Final Exam Module 7 and Study Guide
Bulimia Nervosa Clinical presentation and Physical exam
Demonstrate feelings of shame and embarrassment regarding their symptoms. Do not typically have the physical signs of severe cachexia
Unipolar vs. Bipolar Depression
Depression before age 18, Individual or family history of suicide attempts, Multiple unsuccessful trials of antidepressant medications
M-3 Checklist assesses
Depression, Anxiety, Bipolar disorder
Tuberculosis Vaccination recommendations
Bacille Calmette-Guerin (BCG) is the TB vaccine and is used in people who meet select criteria.
Contemplation Stage of Change Model
Beginning to acknowledge a problem exists but not ready to do anything about it
Dermatitis Pruritus treatment
Benadryl, hydroxyzine, and cyproheptadine - benefit likely sleep. Nonsedating preparations such as cetirizine or loratadine may occasionally be useful.
What is the strongest predictor of psychosis in the postpartum period?
Bipolar disorder
Premenstrual Syndrome physical symptoms
Breast swelling and tenderness, acne, bloating/weight gain, headache or joint pain, appetite alterations
Norepinephrine and dopamine reuptake inhibitors (NDRIs) drug example
Bupropion (Wellbutrin, Zyban)
Mothers with history of mental illness show more disengaged behavior
Disrupts mother-infant bond. Believed to affect infant's neurochemical & neuroendocrine development
Human trafficking Screening
Do not screen in front of suspected abuser. Screening questions may include the following: (a) Tell me about your living situation, (b) "Has anyone ever asked you to have sex in exchange for money, food, shelter, or other items?", (c) "Has anyone ever threatened violence if you attempted to leave?", (d) "Has anyone ever threatened your family if you leave?"
What are the three major neurotransmitters that modulate mood?
Dopamine, serotonin and norepinephrine
Premenstrual Dysphoric Disorder first choice OCP
Drospirenone
Persistent Mood Disorder is also known as
Dysthymia
Varicella Diagnosis
ELISA, tissue biopsy and culture, varicella IgM/IgG
Lupus labs
ESR and CRP in the acute phase are increased, CBC with diff
The binge-eating episodes are associated with three or more of the following
Eating much more rapidly than normal -Eating until feeling uncomfortably full, Eating large amounts of food when not feeling physically hungry, Eating alone because of being embarrassed by how much one is eating, Feeling disgusted with oneself, depressed, or very guilty after overeating
Dermatitis Predisposing factors
Family hx of atopic triad: Dermatitis, asthma, and allergic rhinitis. Stress. Skin irritants: Harsh soaps, skin-care products with perfumes
Lupus signs and symptoms
Fatigue, Fever, Myalgia, Weight change, Arthritis and arthralgias, Skin and mucous membrane involvement, "the butterfly rash, Vascular disease may include: raynaud phenomenon, vasculitis, thromboembolic disease, Renal involvement, lymphadenopathy and splenomegaly, gastrointestinal involvement, neuropsychiatric involvement, ophthalmologic involvement, Hematologic abnormalities, pulmonary involvement, cardiac disease
Dermatitis Diagnostics
C&S to determine viral, bacteria, or fungal etiology. Serum IgE is elevated with atopic dermatitis.
Citalopram (Celexa) 5-10mg start 20-40mg usual dose
First line treatment for ALL anxiety disorders. Start dosing low and titrate up slowly. Will likely need higher dosages than patients with depression Common SE's weight gain and sexual dysfunction. May take 4-6 weeks to have effect. Medications should not be stopped abruptly
Review of symptoms for depression in women?
Headaches, constipation, diarrhea, GI upset, fatigue, sleep disturbances, changes in cognition or memory, appetite derangements, or chronic pain
What can cause lithium toxicity in pregnancy?
Hyperemesis
When should you increase the dose for major depressive disorder medications?
If less than 25% decrease in symptoms, increase dose.
Allergic contact dermatitis
Immunologic response after exposure to an agent. Common Triggers: Nickel, occupational exposure to chromate (cement and industrial processes), poison ivy/oak, chronic exposure to water (hairdresser, bakers), friction (poorly fitted clothing),contact with chemicals or solvents (rubber, neoprene), topical antibiotics, jewelry
Perinatal Mood Disorders
Increased risk for Psychiatric Disorder, Pregnancy, Childbirth, Adjusting to newborn care--*Distress quietly and in shame due to not feeling expected joy during pregnancy*
Premenstrual syndrome psychological symptoms
Irritability, mood swings, crying spells, depression. Other S/S interfering with normal activities are migraines, emotional distress, destabilizing seizure disorders
Preparation Stage of Change Model
Is considering taking action and is gathering information to prepare the action
Persistent Mood Disorder (Dysthymia) differs from major depression how?
It is chronic, low grade symptoms instead of episodic courses.
Dermatitis Symptoms
Itching impossible to relieve, dryness, discoloration, lichenification and scaling, skin thickening, associated bleeding and oozing skin.
Postpartum Blues Duration
Less than 2 weeks
Raynauds medications
Long acting calcium channel blockers: Nifedipine and Amlodipine - Low dose aspirin for secondary RP
Anorexia symptoms
Loose fitting or baggy clothes are common attire, Vital sign abnormalities include depression of core body temperature and bradycardia. However, heart rate may manifest tachycardia in the event of dehydration, Dry skin, decreased turgor, thinning hair, lanugo, protruding ribs and dramatically reduced abdominal girth, abnormalities in heart rhythm, motor weakness, Hypothyroidism secondary to malnutrition may result in a characteristic latency in deep tendon reflexes.
Osteoporosis manifestations
Loss of height, kyphosis or dowager's hump, back pain as a result of compression factor, cervical lordosis, fracture with little or no trauma, crush fracture of vertebra, pain
Varicella S/Sx
Low-grade fever, mild malaise, skin lesions or rash (vesicular exanthem in crops beginning on head/neck and progressing down), itching, myalgia 1-4 days. PRIOR to onset of rash, cough, headache, abdominal pain
Substance Abuse
Maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following occurring in a 12 month period. 1. Failure to fulfill major role obligations (school, work, family etc.) 2. Recurrent use @ times when physically hazardous (while driving etc.) 3. Associated with recurrent legal problems 4. Continued use despite social/ interpersonal problems caused by use
Substance Dependence
Maladaptive pattern of substance use, leading to clinically significant impairment or distress as manifested by three or more of the following in a 12 month period 1. Tolerance - need for increasingly more of a substance 2. Diminished effect with continued use 3. Withdrawal when not using substance 4. Substance is often taken in larger amounts than intended 5. Great deal of time is spent on obtaining, using or recovering 6. Important life and social events are given up to use 7. Use is continued despite knowledge of problem
Opioids
Methadone, Fentanyl, Barbiturates, Benzodiazepines
DMARD
Methotrexate, sulfasalazine, and leflunomide have shown evidence of comparable efficacy.
Postpartum Blues Degree of Disability
Mild to minimal, Able to care for self and child, Suicidal ideation unlikely
Bipolar Disorder treatment
Mood stabilizers are crucial for management and prevention of Post Partum psychosis and mania
Persistent Mood Disorder (Dysthymia) diagnosis
More likely to be suggested by patient. Most often seen in women with thyroid disease, migraine, chronic fatigue syndrome, fibromyalgia, and chronic pelvic pain.
Dermatitis Subacute
More organized, associated with excoriation, scaling, and erythematous papules or plaques.
PUD risks
NSAID and aspirin use, H. pylori infection, smoking, stress, and excessive alcohol use
MAOIs & Tricyclics need to know
Narrow therapeutic range, potential for high toxicity, and food interactions
Norepinephrine and dopamine reuptake inhibitors (NDRIs)
No benefit on anxiety
Arthritis, Juvenile Idiopathic Treatment
No cure - goal is improve QOL. Medications- NSAIDs, corticosteroids, DMARDs. Physical therapy, splints, and orthotics.
Diagnosis of Raynaud's
No gold standard. History alone is acceptable.
Contact Dermatitis Testing
None is source is known. Wet mount for fungal infection if candida is suspected - C&S if pustules. Patch test to r/o allergic dermatitis
Premenstrual Dysphoric Disorder symptoms
One or more must be present--Marked affective lability, Mood swings. One or more must be in addition-- Decreased interest in usual activities, Concentration difficulty, Lethargy or easily fatigued, Marked change in appetite, Overeating, Specific cravings, Hypersomnia/insomnia, Sense of being overwhelmed or out of control, Breast tenderness/swelling, weight gain/bloat, myalgia/arthralgia
The Stages of Change Model
Originally developed to assess the process of change in behaviors such as addictions. *Offers an effective way to assess for and provide appropriate stage-based counseling and resources to women living with abuse*. Can be used for past and present experiences. Assessing where the patient is emotionally can help to facilitate them to move onto the next stage.
Validated screening tools used during pregnancy
PHQ-2, *Edinburgh Postnatal Depression Scale(EPDS)*--Most widely used and most researched, PHQ-9, Pregnancy Depression Scale
Cholelithiasis Treatment
Pain control: NSAIDs or opioids. Aggressive IV hydration to reduce BUN levels. ERCP for patients if cholangitis is suspected to remove impacted stone. - Cholecystectomy in patients with recurrent attacks.
When to Refer to Mental Health Specialties--Emergent intervention is needed as soon as possible if
Patients are assessed as being at risk of harming themselves or others, Patients are so profoundly impaired by their symptoms that their own health is acutely suffering, Patients are experiencing symptoms of serotonin syndrome, serotonin withdrawal, neuroleptic malignant syndrome, or lithium toxicity, The provider is unsure of these risks
Arthritis, Juvenile Idiopathic S/Sx
Persistent joint swelling, fever, warmth of the joint, rash, limping, favoring one limb over the other, stiffness upon waking, inability to bend or straighten completely, fatigue, decreased physical activity, sleep issues, swollen lymph nodes, weight loss
•Persistent Mood Disorder (Dysthymia) treatment
Pharmacotherapy is most effective and may be lifelong.
Mentall illness affects on pregnancy
Possible adverse effects on pregnancy;Increased risk for complications, Preeclampsia, Fetal growth restriction, Prematurity, Miscarriage, Teratogenicity
Postpartum mood disorders range
Post partum blues (aka "Baby Blues"), Post partum depression, Post partum psychosis
Varicella
Primary varicella results in diffuse vesicular rash of chickenpox. Virus remains dormant in the sensory nerve roots for life. Reactivation known as shingles.
PHQ-2
Quick depression scale
Contact Dermatitis Symptoms
Ranges from redness to pruritic inflammation with possible progression of blisters. Typically indistinctive boarders localized to the region of contact. Fissured and painful. Poison oak/ivy presentation: Lesions (vesicles) and papules on an erythematous base presenting in a linear fashion with sharp margins. Exposure to some irritant known to patient: Round or annular lesions.
Diagnostic Criteria for Bulimia Nervosa
Recurrent compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diruretics, enemas, or other medications, fasting or exercise. The binge eating behaviors both occur, on average, at least twice a week for 3 months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of Anorexia Nervosa
Benefits from stopping smoking include
Reduced heart attack risk within the 1s t year, Reduced stroke risk within 5 yrs, Lung CA risk reduced by 50% within 10yrs
Diagnostic Criteria for Anorexia Nervosa
Refusal to maintain body weight at or above a minimally normal weight for age and height, Intense fear of gaining weight or becoming fat, even though underweight, Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight, In postmenarcheal females, amenorrhea
Atopic Dermatitis Treatment
Regular use of moisturizers. Topical high potency steroids during flares-- BID to induce remission. limit 1-2 weeks - Topical calcineurin: Anti inflammatory that is thought to be equivalent to mild potency. corticosteroids. LESS likely to cause skin atrophy. 2nd line therapy. Avoid problematic foods and environmental irritants. Wear light, soft clothing. Reduce stress. Oral antihistamines offer no control, but help with sleep and allergies. Oral Vitamin D found to reduce flares in 80% in some trials. Mild to moderate cases not adequately controlled with topical therapy can use phototherapy with narrowband UVB rays.
Irritant Contact Dermatitis Treatment
Removal of irritating agent. Use of topical soaks with saline or Burrows solution for weeping areas - Lukewarm baths (NOT hot), or oatmeal (Aveeno) baths prn. For dry/erythematous areas: Aquaphor, Vaseline, Eucerin. Keep nails short--do not scratch.
Diagnostic Criteria for major depressive disorder
SIGECAPS Questionnaire - Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicide
Purging type Bulimia Nervosa
Self-induced vom iting or the m isuse of laxatives, diuretics, or enem as
Postpartum Depression Degree of Disability
Severe, Decreased bonding with infant, May need assistance to care for infant, May have suicidal ideation
Major Depressive Disorder Symptoms
Sleep disturbances, lack of energy, appetite changes, digestive difficulties, headaches, and unexplained body pains, memory loss, weight gain/loss, decreased libido, feelings of guilt or hopelessness, suicidal thoughts or hallucinations, slowed thinking, poor concentration/retention, confusion, vague decision-making
Persistent Mood Disorder (Dysthymia) symptoms
Sleep, appetite disturbances, poor concentration, fatigue, feelings of isolation and low self-esteem, but lacks thoughts of self injury.
Premenstrual Syndrome Treatment
Stabilize well being, Exercise, Nutrition, General stress management, Controlling menstrual cycle, Minimize hormone fluctuation, *Suppress ovarian function*
Varicella Treatment
Strict isolation, oatmeal baths for comfort, tylenol for fever, Acyclovir if initiated within 24 hours of rash, Benadryl, corticosteroids, vaccination
Pancreatitis Treatment
Supportive care to manage N/V, and pain. Correct fluid and electrolyte imbalances. Treat infection if present. Immediate goals of care is to reduce BUN levels through aggressive IV hydration.
Cholelithiasis
Symptomatic gallstones--incidence greater in women than men and increases with age
Influenza treatment
Tamiflu (oseltamivir)-75 mg BID for 5 days. Preferred when in pregnancy. ▪ Tamiflu- Prophylaxis- 75 mg once a day for 10 days
Postpartum Blues Common Symptoms
Tears, Sadness, Labile mood, Irritability, Sense of being overwhelmed, Frustration
Postherpetic Neuralgia
The condition affects nerve fibers and skin, causing burning pain that lasts long after the rash and blisters of shingles disappear· Most commonly occurs after shingles.
Urgent intervention is needed within 1 week when
The patient is assessed as being at high risk for suicide yet is currently safe, Other psychiatric comorbidities are present, including substance use disorder, There is an indication for electroconvulsive therapy.
Chronic Eczema
Thickened and lichenified skin
Atopic Dermatitis
Thought to be a result of interactions between genetics and environment. may present with allergic rhinitis and eczema. Triggered by emotional stress.
Cholelithiasis Diagnosis
Transabdominal ultrasound most sensitive. Labs may be done to check for infection or complications - CBC, LFTs, bilirubin, amylase, lipase, triglycerides, renal panel, CRP, lactate dehydrogenase
Trauma-Informed Care
Treatment framework used to care for survivors of any type of trauma that are now seeking help. Involves understanding, recognizing, and responding to the long-term effects of trauma. Emphasizes physical, emotional, and psychologic safety. Aids survivors in rebuilding a sense of control and becoming empowered.
Varicella vaccine
Two vaccines available: MMRV and monovalent varicella vaccine.
Mental Health Screening
USPSTF recommends screening for depression routinely only when staff- assisted depression care support are in place for adequate diagnosis, treatment, and follow up
HIV USPSTF Screening recommendations
USPSTF- recommends that everyone ages 15-65 should be screened annually for HIV.
Major Depressive Disorder Follow-up
Under-treatment is common--perform screening tests at every visit *(every 2-3 months)*
Perinatal Depression Management
Urgent/Immediate Referral - high risk of suicide or homicide
Allergic Contact Dermatitis Treatment
Wash affected area with cool water immediately after exposure - Lukewarm oatmeal baths 3-4 times a day. Apply Calamine lotion immediately after bathing.
SSRIs interact with?
*CPY450* - med interactions esp with *tricyclic antidepressants, digoxin, warfarin, anticonvulsants, and theophylline*
Untreated mental illness in pregnancy disrupts
*the HPA axis*--Subtly affects fetal development, Increase uterine irritability, Increased vulnerability of fetus to future depression/anxiety
Postpartum Depression Onset
2 months - 1 year after birth
Vesicle
< 0.5 has serous fluid
CDC HIV pregnancy recommendations
ALL women be screened in 1st trimester and again in 3rd if risk factors present
GAD-2 assesses
Anxiety
HIV Diagnosis is made when
CD4 count LESS than 200.
Birth associated with psychological and biological transitions
Decreased estrogen levels, Decreased serotonergic activity following birth, Downregulation of the hypothalamic-pituitary-adrenal axis following birth
Depression diagnostic labs
Elevated TSH, Elevated free T4, Elevated Thyroid autoantibodies
Dermatitis Acute
Erythema, edema, vesiculation with weeping of acute lesions, severe pruritus
HIV symptoms
Fatigue, fever, night sweats, loss of appetite and weight, rash, anemia, neutropenia, thrombocytopenia, dyspnea, thrush, Kaposi's Sarcoma, hepatosplenomegaly, hairy leukoplakia, esophageal candidiasis
Non Benzodiazepine Anxiolytic Buspirone (Buspar) 7.5mg start 20-30mg usual dose
GAD only (FDA approval). May exacerbate depressive symptoms. Common SE - fatigue & dizziness. May take 4 weeks to take effect
SSRI Side effects
GI upset, Weight gain, jitteriness, headache, sexual dysfunction
Primary Causes of pancreatitis
Gallstones, ETOH induced, drug related, hereditary conditions, post ERCP-induced, infections (viral, mumps, mono), HLD, hypercalcemia, pregnancy, idiopathic, trauma, venom, hypertriglyceridemia > 1000 mg/dL
Norepinephrine and dopamine reuptake inhibitors (NDRIs) side effects
Generally less weight gain and sexual side effects than SSRIs, but lowers threshold for seizures.
How should medications be dosed for major depressive disorder?
Generally, response to drugs is slow, 6 weeks for maximum effect • Taper down dose when discontinuing medication
Cholelithiasis Risk Factors
Genetic predisposition, sedentary lifestyle, diabetics, diet rich in animal and refined sugars, cirrhosis, and certain medications, hx of gastric bypass, pregnancy, oral contraceptives or HRT (estrogen increases saturation of bile with cholesterol & progesterone reduces gallbladder contractions and increases stasis.)
Postpartum Depression Duration
Greater than 2 weeks
Postpartum Psychosis Degree of Disability
High risk-- Risk to child or children
Bipolar Disorder treatment in pregnancy
Lithium is safest during pregnancy--Monitor levels closely
Irritant contact dermatitis
NONimmunologic response.
Lupus Medications
NSAIDs, Prednisone, Corticosteroids, Hydroxychloroquine sulfate, Alternate therapy: immunosuppressive agents: cyclophosphamide, chlorambucil, and azathioprine in resistant cases
Basal cell carcinoma
Nodular tumor with *pearly* surface, telangiectasia on surface, and *depressed center or rolled edge*. MOST COMMON. Found mostly on head and neck
Nonpurging Type Bulimia Nervosa
Other inappropriate compensatory behaviors, such as fasting or excessive exercise.
USPSTF recommends what routine screening for major depressive disorder?
PHQ-2, PHQ-9
Serotonin syndrome needs what immediately?
Referral to ER
Medications for major depressive disorder
Selective serotonin reuptake inhibitors (SSRI):First line treatment
Inhalants & Steroids
Vapor inhalation of solvents (paint & glues), Nitrous oxide, Anabolic steroids, Commonly abused prescription drugs
referred
aching and perceived to be near the surface of the body
mild acute pancreatitis
characterized by the absence of organ failure
Physical signs of self-induced vomiting
dental erosion( interior aspects of molars), Russell's sign (abrasion or scarring on the carpometacarpal joints) and enlarged salivary glands.
tertiary
minimize effects of disease ▪ surveillance and maintenance ▪ leep, HTN management
severe acute pancreatitis
persistent organ failure that may involve one or multiple organs
parietal
sharp and well located
Tuberculosis Active
a condition in which your body's immune system is unable to fight off the TB bacteria, therefore causing infection in the lungs or other parts of the body and the person shows symptoms of TB. spread through respiratory transmission of droplet nuclei
The most significant risk factor for mental illness in pregnancy/postpartum is
a history of previous mental illness in the patient or family.
Manic episode defined by
a period of time (at least one week) when a person's mood is abnormally elevated, expansive, or irritable in addition to at least three of the following symptoms: Inflated self-esteem (grandiosity), Decreased need for sleep without fatigue, Pressured speech, Racing thoughts, Distractibility, Psychomotor agitation, Excessive involvement in pleasure-seeking activities that have high risk for undesirable consequence
Rheumatoid Arthritis (RA) diagnosis
CBC, ESR, CRP, Rheumatoid factor (quantitative), CCP antibody, uric acid level, synovial fluid, Antinuclear Antibody.
What needs to be done and what needs to be ruled out with Osteoporosis
CBC, ESR, and serum protein to r/o multiple myeloma and leukemia
Skin Cancer Screening
CDC does not provide recommendations on visual skin examinations by a clinician
Colon Cancer screening
CDC recommends: Adults 50-75 years old ▪ screening every 1-3 years with FIT (fecal immunochemical test) ▪ screening every 10 years with flex sig and every 1-3 year FIT ▪ screening every 10 years with colonoscopy ▪ screening every 5 years with CT colonography
Management of osteoporosis
Calcium intake: Men up to 69 years old: 1000 mg PO daily. Men age 70+ 1200 mg PO daily. Women < 50 years old 1000 mg PO daily. Women age 50+ 1200 mg PO daily. Vitamin D intake: Women and men < 50 year old: 400-800 IU PO daily - Women and men age 51+ 800-1000 IU PO daily *Bisphosphonates = 1st line treatment--reduces bone resorption and bone loss. Fosamax* (alendronate sodium), Actonel (risedronate), Reclast (zoledronic)
Psychomimetics & Hallucinogens
Cannabinoids, PCP, LSD, Mescaline, Psilocybin, Ecstasy, Ketamine
SSRI meds
Celexa, Lexapro, Prozac, Paxil, Zoloft
Arthritis, Juvenile Idiopathic
Chronic idiopathic inflammatory disorder of the joints in children
Psoriasis
Chronic, immune-mediated disorder that encompasses genetic predisposition and environmental triggers. A papulosquamous disease manifested as *scaling with papules and plaques*. Lesions are sharply marginated with a *silvery white scale*
Nicotine
Cigarettes, Chewing tobacco, e-Cigarettes or Vapor
Action Stage of Change Model
Client is taking action to change or address her situation
CNS stimulants
Cocaine, Amphetamines, Methamphetamines, Ecstasy
Cholelithiasis Symptoms
Colicky, stabbing, spasmodic pain in the epigastric area or RUQ, often radiates to the right scapula area, lasting 2-4 hours per episode. * Pain caused by impaction of gallstone in the cystic duct, leading to gallbladder distention.
Premenstrual Dysphoric Disorder treatment
Control Cycles, Minimize hormone fluctuation, Continuous therapy of monophasic product, Extended or continuous use of oral contraceptives, Vaginal ring, Birth control patch, *Drospirenone is first-choice OCP*
Dermatitis Acute flare treatment
Cool compress and topical steroid creams. Oral steroids for severe cases.
Patient Education for SSRI
Counsel on abrupt discontinuation leading to withdrawal. Must taper! *Side effects usually resolve within 2 weeks*. Gradually increasing dose improves likelihood of compliance.
Prenatal Depression Symptoms
Crying, Weepiness, Sleep problems, Fatigue, Appetite disturbance, Adhedonia, Anxiety, Poor fetal attachment
Contact Dermatitis
Cutaneous response to direct exposure of the skin to irritants or allergens.
CAGE test
Cutting down / Annoyed by complaints / Guilty about use / Eye opener
Serotonin norepinephrine reuptake inhibitors (SNRIs) drug examples
Cymbalta, Effexor
Benzodiazepine Anxiolytics
*Alprazolam (Xanax)* 0.25mg to 0.5mg two to three times daily, *Clonazepam* 0.25m g to 0.5m g one to three tim es daily (can be titrated up to 1m g two to three times daily), *Lorazepam (Ativan)* 0.5m g to 2m g in divided doses (up to 10m g daily). *Use for short term stabilization or as breakthrough supplement with SSRI/SNRI medication* *Can be used while attempting to transition to Buspar* Dependence potential is high
Diagnosis of osteroporosis
*DEXA* measures bone density of lumbar spine and/or hip, *FRAX (fracture risk assessment tool)* may be used in conjunction with BMD results to evaluate the need for fracture prevention medication. *CMP, TSH, and 25-hydroxyvitamin D level*
treatment for latent TB
1st line - Isoniazid (300mg daily for 9 months)
Postpartum Psychosis Onset
2-4 weeks after birth
Influenza Specimen should be obtained within
5 days of symptom onset for immunocompetent individuals. o RT-PCR is the most sensitive and specific test. - available results in 4-6 hours.
Postpartum Blues Onset
7-10 days after birth
Papule
<1cm elevated area
Bulla
>0.5 has serous fluid
Patch
>1 cm Discoloration
Nodule
>1 cm elevated lesion
Plaque
>1cm elevated area
Tumor
>2 cm
Postpartum Psychosis Symptoms
Acute onset, Delusional thoughts, Hallucinations, Paranoia, Confusion, Insomnia, Deliruim
Hepatitis C Management
Acute: antivirals and supportive treatment Chronic- regular monitoring for signs of liver disease progression, new direct acting antiviral medications offer shorter durations of tx and increased effectiveness.. *HCV + moms safe to breastfeed*
CNS sedatives
Alcohol, Barbiturates, Benzodiazepines, Opioids
Application of the model focuses on shared decision making
Allow the women control of the healthcare visit. Remain in own clothing. Decide the order in which the exam is done. Pelvic exam , offer a mirror
Despite the few physical symptoms of depression, it is important to rule out disorders that have psychiatric symptoms such as
Anemia (CBC), Thyroid (TFTs), Diabetes (Hb A1C), Drug Addiction (tox screen), Eating Disorder (serum electrolytes, LFTs, Dexa, EKG)
Postpartum Depression Symptoms
Anhedonia, Sleep disturbances, Feelings of loneliness and isolation or guilt, Poor concentration, Anxiety, Somatic complaints
When does suicide risk increase with depression medication dosing?
As lethargy begins to lift with initial treatment, risk of suicide attempts increase in first 1-2 months.
ABCDE
Asymmetry, uneven borders, color changes, diameter >6mm, and evolving status.
Postpartum Psychosis Duration
Average around 40 days
Dermatitis Treatment
Avoid triggers such as heat and low humidity. Treat stress and anxiety. Use antihistamines for sedation and control of itching. Treat dry skin with emollients. Pat, do not rub. Keep moisturized with Vaseline, Aquaphor, or Eucerin BID and after bathing - Avoid wool and lanolin preparations. Eliminate food triggers one at a time for 1 month - start with cows milk.
Contact Dermatitis Treatment
Avoidance of irritant or allergen. Cool compress. Non soap cleansers to reduce dryness. Emollients for rehydration. Topical corticosteroids for inflammation
obturator
abdominal pain response to passive internal rotation of the right hip from the 90 degree angle knee-hip flexion ● appendicitis
Osteoarthritis Arthritis diagnosis
able to make dx if persistent usage related joint pain, age>45, and morning stiffness lasting <30 minutes
Clinical features of pancreatitis
acute onset of persistent, severe *epigastric abdominal pain* pain may be in the left upper quadrant and radiates to back left shoulder. with gallstone related pancreatitis RUQ pain may initially occur, N/V which persist for several hours, fever, knife like pain, jaundice, clay colored stool
USPSTF alcohol recommendations
adults aged 18 and over be screened for alcohol misuse and then be provided intervention to reduce alcohol misuse if deemed necessary
Influenza Symptoms
affect the oropharyngeal and bronchial airways. Like the common cold but more severe o Fever, chills, malaise, myalgia, cough, and headache.
Malignant melanoma
asymmetric papule, with irregular border of two or more colors and size varies.
Premenstrual Dysphoric Disorder Diagnostic criteria
at least 5 symptoms must be present • *Only one can be physical* • Present in final week before menses onset • Start to improve within days of menses onset • Become minimal or absent in week post menses • Must be present for at least 2 symptomatic cycles • Must rule out other causes (drug abuse, hypothyroid, etc)
Serotonin syndrome symptoms
autonomic instability, neuromuscular signs, and cognitive behavioral signs. Fever, hyperreflexia, diarrhea, diaphoresis, myoclonus, tremor, agitation, confusion or hypomania
HIV+ moms should NOT
breastfeed
Hepatitis B prevention
childhood vaccination is the standard recommendation. adult vaccination for those at high risk. HBIG is recommended post-exposure in unvaccinated individuals. Vaccine schedule: infants and children-3-4 doses given over 6-18 months Adults- 3 doses over 6 months
CDC recommends HPV vaccinations for
children >9 ▪ 2 dose series for children 9-14 ▪ 3 dose series for children >15 ▪ This is different only if there is a history of sexual abuse/assault (begin series at 9) or immunocompromised condition (9-26yo, 3 dose series).
Osteoarthritis Arthritis
chronic non inflammatory moveable joint disease formerly known as DJD that consists of the breakdown of cartilage between joints. *the most common form of arthritis* peak age 65
Human trafficking Red flags
conceal abuse, lie about injury or illness, evidence of physical and/or sexual violence, discrepancy between suspected and reported age, self-inflicted injuries, addiction use disorders, chronic medical conditions, multiple or recurrent STIs, and the presence of a controlling person (partner, employer, or family member)
Hepatitis C transmission
contact with blood of an infected person through sharing contaminated needles, syringes, or other injection drug equipment. less commonly through sexual contact, birth, blood transfusions, or hemodialysis
Rheumatoid Arthritis (RA) treatment
daily NSAIDs, oral glucocorticoids (prednisone 5-10mg/day), intra-articular long-acting glucocorticoid injections to reduce synovitis, DMARDs (disease-modifying antirheumatic drugs), methotrexate (MTX)(Immunosuppressive drug therapy) is given weekly starting at 7.5mg and increased as tolerated for symptom control after the first 4 weeks, sulfasalazine (azulfidine) 500-1000 mg/day, hydroxychloroquine (plaquenil) 200-400 mg daily, leflunomide (arava) 10-20 mg/day
Perimenopause is a particularly stressful time and a woman who gives a history of premenstrual distress, dysphoric mood with hormonal contraceptives, postpartum illness, or any prior episode of mental illness is particularly at risk for?
developing psychiatric illness in middle age
Children of depressed mothers show what symptoms?
developmental and cognitive delays, conduct and behavior disorders.
Rheumatoid Arthritis (RA)
differentiate from other forms of arthritis-- chronic systemic disease that involves articular inflammation of the joint, generally insidious and has *symmetrical involvement of synovial joints*, typically involves interphalangeal joints, elbows, shoulders, ankles, knees, and toes, associated with an increased risk of carpal tunnel, stroke, osteoporotic fracture, and renal disease
Gastritis treatment
discontinue medications like NSAIDs, discontinue alcohol use, antacids, H2 receptor blockers (antagonists), proton pump inhibitors (PPIs), antibiotics - treat H. Pylori, best when used with PPI and antidiarrheal, antidiarrheal agents - used with PPI or H2 blockers
Pre-contemplation Stage of Change Model
does not acknowledge that there is a problem
GERD alarm symptoms include
dysphagia, unintentional weight loss, severe upper abdominal pain, hematemesis, melena, and odynophagia
secondary
early detection and intervention ▪ reverse, halt, retard the progression of a disease/injury ▪ tobacco cessation, pap smear ▪ BP Screenings, etc.
Gastritis s/s
epigastric pain, bloating, n/v, anorexia, weight loss
Gastritis diagnosis
erythema, erosions, subepithelial hemorrhage of stomach lining
Serotonin syndrome is caused by
excess serotonin levels due to combining SSRI or SNRI with medications such as metoclopramide and ondansetron, triptans, anticonvulsants, tramadol, some opioids, or recreational drugs such as amphetamines, cocaine, and ecstasy, as they have serotonergic activity.
Hepatitis B transmission
exposure to blood, blood by-products, contaminated needles, saliva, vaginal secretions, and semen
Hepatitis A transmission
fecal-oral route--contamination of food and water are common sources of infection
Tuberculosis s/s
fever, malaise, fatigue, night sweats, weight loss, chills, decreased appetite, persistent cough, productive sputum with or without hemoptysis, chest pain, lymphadenopathy *Most commonly found in Asians/Pacific Islanders/Native Hawaiians*
Macule
flat <1 cm of discoloration
What does psoriasis affect most commonly?
frequently affects elbows, knees, and scalps Associated with increased risk of arthritis, CVD, and cancer. Psoriasis Treatment;Vitamin D analogues and corticosteroids. Topical anthralin, tazarotene, phototherapy, and oral methotrexate
Women with an unintended pregnancy
have a higher risk (3 x in one study) of physical abuse compared with women who had a planned pregnancy
Moxibustion
heat therapy
Raynaud's Phenomenon
idiopathic disease resulting in an exaggerated vascular response in extreme circumstances
Women are most likely to hospitalized for a psychiatric illness when?
in the 1st year postpartum.
Tuberculosis Latent
inactive form and indicates that the person has been exposed. no lung damage, asymptomatic and non-contagious, at greater risk of developing active TB. Key sign is erythema nodosum or Phlyctenular conjunctivitis caused by a hypersensitivity reaction to TB bacterium - causes small grey or yellow nodules in the conjunctiva that result in discomfort, pain, and increased tearing of the affected eye
Osteoarthritis Arthritis s/sx
increased pain when joint is in use, morning stiffness of joints <1 hr, reduced passive and active range of motion from marginal osteophytes and capsular thickening swelling and joint instability, Non-inflammatory disease that affects the movable joints, Women are more commonly affected and older than 55 years, *Unilateral joint pain* frequently involving the joints of the hands, neck, lower back, knees and hips. Pain increases with joint use and decreases with rest, Proximal Interphalangeal Joints (PIP) - Bouchard's nodes or Distal interphalangeal joint (DIP)- Heberden's nodes
SSRIs Citalopram (Celexa)
initiating dose 10-20 mg. *Good choice for anxiety*, fewer sexual side effects than other SSRIs, weight gain common, *increase after 4 weeks*. Skipping dose can cause serotonin withdrawal symptoms
SSRIs Fluoxetine (Prozac)
initiating dose 10-20mg. Weight gain common, sexual side effects. More activiating than other SSRIs. *Least like of all SSRIs for withdrawal symptoms*
SSRIs Esctialopram (Lexapro)
initiating dose 10mg. *Good choice for anxiety,* Weight gain common, similar long-term sexual side effects as citalopram. Missing dose can cause serotonin withdrawal symptoms
SNRIs Duloxetine (Cymbalta)
initiating dose 20-30mg. Weight-neutral in short term, unknown in long term. Fewer short term sexual side effects than SSRIs. Monitor BP and for neuropathic pain. Withdrawal symptoms reported
SSRIs Paroxetine (Paxil)
initiating dose 20mg. Weight gain more likely than other SSRIs. Sexual side effects more likely short term. *Sedating effect. Significant serotonin withdrawal effects*
SNRIs Venlafaxine (Effexor)
initiating dose 37.5mg. Weight-neutral. Fewer sexual side effects than SSRIs. Increases BP in dose-dependent fashion. More agitating, more GI symptoms than SSRIs. Withdrawal symptoms reported
SSRIs Sertraline (Zoloft)
initiating dose 50mg. Weight gain most likely after 6 months. Sexual side effects. *Withdrawal symptoms are less likely*
NRDIs Buproprion(Wellbutrin/Zyban)
initiatingdose100mgtwotimes/day. Bupropion SR 12 hour starting dose 100mg. Contraindicated in history of seizure disorder or TBI, as may be stimulating. No sexual side effects. Minor weight loss. Withdrawal symptoms not reported
Squamous cell carcinoma:
irregular papule, with scaly, friable, bleeding surface. Usually presents as a flat, reddish patch or bump and may have a rough surface.
Lupus
is a chronic inflammatory disease of unknown cause that can affect virtually every organ; joints, kidneys, brain, heart, and lungs. production of abnormal antinuclear antibodies are a prominent feature
Varicella Transmission
is airborne droplets from respiratory secretions onto the conjunctival or nasal/oral mucosa, and direct contact with lesions.
Lupus goal
is to ensure long-term survival, achieve the lowest possible disease activity, prevent organ damage, minimize drug toxicity, improve quality of life, and educate patients in their role in disease management
Arthritis, Juvenile Idiopathic Pathogenesis
is unclear- combination of genetic factors, immune mechanisms, and environmental exposures • Several types of JIA;*Systemic arthritis*- immune system attacks the joints *Polyarthritis*- affects more than 5 joints after the child has it for 6 months • *Oligoarthritis*- affects less than 5 joints after child has it for 6 months (most common) *Enthesitis*-related arthritis- leg and back joints *Psoriatic arthritis*- may affect one to many joints, causes rash and nail changes
treatment for active TB
isoniazid, rifampin, ethambutol, pyrazinamide together for 2 months▪ then isoniazid and rifampin for an additional 4 months *monitor liver enzymes*
Rheumatoid Arthritis (RA) s/sx
joint pain including morning stiffness lasting more than one hour and has been present for at least 6 weeks, swelling and warmth in at least 3 joints for more than 6 weeks, fatigue, malaise, subcutaneous nodules, joint deformities, *Boutonniere deformities* (proximal interphalangeal) and swan-neck contractures, depression, low grade fever, weight loss, myalgias, carpal tunnel
Anticonvulsant mood stabilizers are
known teratogens
Serotonin norepinephrine reuptake inhibitors (SNRIs) side effect
less weight gain and sexual side effects than SSRIs, but increases BP and GI upset.
RUQ pain
liver or biliary tree, suspect cholecystitis ● perform u/s to detect gallstones and biliary tract distention
iliopsoas
lower quadrant pain as the supine patient raises their right leg from the hip while the examiner pushes downward against lower thigh ● appendicitis
Treatment with an antidepressant may trigger
mania, suicidal ideation or psychosis in those with bipolar disorder. BEWARE!
Postherpetic neuralgia treatment
may be treated with narcotics or other pain relieving medications. *Shingles vaccine for all patients 60 years of age and older*
Four Domains of Healing
meta-synthesis done by *Draucker and colleagues* 1. Managing memories 2. Relating to important others 3. Seeking safety 4. Reevaluating self
St. John's Wart
more effective than placebo in mild-moderate depression. Side effects include headache, worsening mood/mania, jitteriness, reduce bioavailability of prescription meds (including oral contraception), can potentiate action of psychotropic drugs
Serotonin syndrome:Use extreme caution when treating with
more than one SSRI or SNRI, MAOIs, lithium, or St. John's wort.
Active withdrawal symptoms
nausea & vomiting/ abd complaints, malaise, weakness, tachycardia, diaphoresis, tremors, dizziness, insomnia, irritability, confusion, perceptual abnormalities, blurred vision, fever, delirium, seizures, tremors
Hepatitis A Management
no medication available; because an acute disease, symptomatic tx and monitoring for worsening liver disease. Pregnancy does NOT affect course - no impact on fetus.
Hepatitis C prevention
no vaccine present, prevention counseling is key
If immediate danger in elder abuse
notify Adult Protective Services and consider admission to the hospital for a more extensive evaluation.
peptic ulcers
often asymptomatic until complications (bleeding, perforation)
McBurney's point
pain ● appendicitis
Hepatitis B Management
palliative care for acute phase; chronic HBV can be treated with antiviral drugs. HBV + moms safe to breastfeed
Binge-Eating/Purging Type anorexia
person has regularly engaged in binge- eating or purging behavior
Osteoarthritis Arthritis treatment
physical therapy, education on the importance of protecting joint (avoid repetitive stress), daily exercise and strengthening, lubrication injections, medications: acetaminophen, NSAIDs, topical creams, corticosteroid injections
Cardinal signs and symptoms of DYSPEPSIA
postprandial fullness, early satiation, epigastric pain, epigastric burning
Murphy's
pressure on RUQ will elicit pain on inspiration ● cholecystitis
primary
prevention of disease/injury ▪ vaccinations, education
PUD and progesterone
progesterone may be GI protective and therefore this is rare in pregnancy
If elder abuse suspected the patient should be
referred to a provider who specializes in geriatrics for a comprehensive geriatric assessment.
Actinic keratosis
rough, scaly patch on your skin that develops from years of exposure to the sun. Most common on face, lips, ears, back of hand, forearms, scalp, and neck. Can become cancerous.
USPSTF recommendations for HPV screening
screening every 3 years for HPV for women 21-65. Co-testing can extend HPV testing to every 5 years after age 30.
Diagnostic clue of shingles is
sensory symptoms that do NOT cross the midline.
Physical signs of drug and alcohol use
sider angiomas, ruddy nose or face, nasal lesions, bruxism, swollen features, bruises, needle marks/tracks, cutaneous abscesses, malnourished, anemia, jaundice, severe dental issues
Physical exam for pancreatitis
significant tenderness to palpation in the epigastrium or more diffusely over the abdomen, HEPATOMEGALY in alcoholic pancreatitis, *Cullen's Sign may occur in some - ecchymosis and edema in subcutaneous tissue around umbilicus and Grey Turner's Sign is ecchymosis of the flank*
Tuberculosis diagnosis
skin test (PPD), blood test, more accurate (IGRA), CXR - classic: upper lobe infiltrates and unilateral hilar node enlargement, AFB (acid fast bacillus), sputum cx
Women are more likely to experience what kinds of symptoms when anxious or depressed?
somatic symptoms when they are anxious or depressed such as appetite changes, sleep disturbances, fatigue, and pain rather than emotional distress
Federal Bureau of Prisons
still recommends preventive services specific to women such as PAP testing, mammograms, and STI screening.
Gastritis
stomach lining is either inflamed or swollen causing injury, cell damage, or regeneration o causes:infectious agents (H. pylori), spicy/salty foods, alcohol, NSAIDs, stress, bile/pancreatic reflux can cause exacerbation in irritation or discomfort
Hemodilution in pregnancy can cause
subtherapeutic levels
RLQ
suspect appendicitis ● CT of abdomen w/w ● u/s or MRI in pregnant women (no contrast)
LLQ
suspect diverticulitis ● CT of abdomen and pelvis with contrast
epigastric
suspect peptic ulcer disease ● upper GI radiography with barium swallow to evaluate for gastric erosions, ulcers, and cancer ● upper GI with small bowel series can be considered if concerns for Crohn's or other small bowel conditions
Osteoarthritis Arthritis typically affects
the hands, knees, hips, cervical and/or lumbar spine and is *associated with overuse, obesity, and joint laxity. usually unilateral and asymmetric*
Restricting Type anorexia
the person has not regularly engaged in binge-eating or purging behavior
If a patient presents with severe symptoms or if she is unable to contract for safety
the situation must be treated as a medical emergency and psychiatric treatment must be obtained to ensure her safety.
moderately severe acute pancreatitis
transient organ failure (resolves w/i 48 hours) and/or local or systemic complications without persistent organ failure (>48hours)
PUD treatment
treatment of H. pylori 1st line - proton pump inhibitors, clarithromycin, AND amoxicillin (or metronidazole) for 14 days. proton pump inhibitors OR H2-receptor blocker, bismuth, metronidazole, AND tetracycline for 14 days
Peptic Ulcer Disease
ulcerations in the stomach or duodenum caused by disruptions in the normal protective mechanisms allowing acid to reach and damage the mucosa
PUD s/sx
upper abdominal discomfor, dyspepsia, heartburn, duodenal ulcers: pain at night, pain with fasting, relieved by eating
visceral
usually dull and aching
Hepatitis A prevention
vaccination of children and individuals at increased risk of disease (international travelers and those working in countries where HAV is endemic. Vaccine schedule: 2 doses given 6 months apart. all children at age 1 year
Seborrheic keratosis
waxy papule with a stuck on appearance is seen in adults. The appear symmetric 0.2-3.0cm in size, with a well-demarcated border and a variety of colors like tan black and brown.
Some cultures believe
women are protected from dark thoughts and negative emotions during pregnancy
Persistent Mood Disorder (Dysthymia) is often seen in
women with thyroid disease, migraines, chronic fatigue syndrome, fibromyalgia, and chronic pelvic pain.