AANP FNP Terms with Pictures

Verruca Vulgaris Lesion ("warts")

-caused by HPV types 1, 2, and 4 -passed thru direct person-to-person contact -over 12 to 24 month period, most of all lesions will disappear without treatment

Uticaria

-eosinophilia

Squamous Cell Carcinoma

-found on sun areas -nodular, opaque lesion -nondistinct borders

Malignant Melanoma

-has variable pigmentation -sunscreen does not reduce the risk for this cancer -asymmetry with nonmatching sides -color is not uniform -recently formed lesion -history of blistering sunburn -consult with skin cancer expert

Dermographism

-hive-form linear lesions that develop over areas where a patient has scratched

Basal Cell Carcinoma

-painless, pearly, ulcerated nodule with overlying telangiectasis -found on sun areas

Actinic Keratoses

-slightly rough, pink or flesh-colored lesion in sun-exposed area -pharmacological treatment: 5-fluorouracil (topical chemotherapy) -non-pharmacological treatment: chemical peel, cryotherapy, laser resurfacing

Anaphylaxis

-upper airway edema -itch without rash -dizziness with syncope

Causes of Tachycardia

1. *Fever* 2. Shock 3. *Hypovolemia* 4. Hypoxia 5. Hyperthyroidism or Hypothyroidism 6. Pain 7. Anxiety 8. Drugs (mnemonic=FAST) a. Free Base (cocaine) b. Anticholinergics, Antihistamines, Amphetamines c. Sympathomimetics, Solvent abuse d. Theophylline

Salter-Harris Fracture Type I

A type 1 fracture is a transverse fracture through the hypertrophic zone of the physis. In this injury, the width of the physis is increased. The growing zone of the physis usually is not injured, and growth disturbance is uncommon. On clinical examination, the child has point tenderness at the epiphyseal plate, which is suggestive of a type I fracture.

Salter-Harris Fracture Type III

A type III fracture is a fracture through the physis and epiphysis. This fracture passes through the hypertrophic layer of the physis and extends to split the epiphysis, inevitably damaging the reproductive layer of the physis. This type of fracture is prone to chronic disability, because by crossing the physis, the fracture extends into the articular surface of the bone. However, type III fractures rarely result in significant deformity; therefore, they have a relatively favorable prognosis. An ankle fracture termed a Tillaux fracture is a type of Salter-Harris type III fracture that is prone to disability. The treatment for type III fractures is often surgical.

Salter-Harris Fracture Type V

A type V injury is a compression or crush injury of the epiphyseal plate, with no associated epiphyseal or metaphyseal fracture. This fracture is associated with growth disturbances at the physis. Initially, diagnosis may be difficult, and it often is made retrospectively after premature closure of the physis is observed. In the older teenagers, the diagnosis is particularly difficult. The clinical history is paramount in the diagnosis of this fracture. A typical history is that of an axial load injury. Type V injuries have a poor functional prognosis.

BMI

A BMI of 20 is in the normal range. A BMI under 18.5 indicates the person is underweight; 25 to 29.9 indicates a person is overweight; 30 - 39.9 indicates a person is obese; and a grossly obese person has a BMI of over 40.0.

Salter-Harris Fracture Type IV

A Type IV fracture involves all 3 elements of the bone, passing through the epiphysis, physis, and metaphysis. Similar to a type III fracture, a type IV fracture is an intra-articular fracture; thus, it can result in chronic disability. By interfering with the growing layer of cartilage cells, these fractures can cause premature focal fusion of the involved bone. Therefore, these injuries can cause deformity of the joint.

Iron Deficiency Anemia

A. Symptoms: 1. Fatigue 2. Generalized Weakness 3. Dyspnea on Exertion 4. Lightheadedness B. Signs: 1. Pale Conjunctiva or Mucous Membranes 2. Pallor at Nail Beds 3. Tachycardia 4. Melena (dark, tarry stool) 5. Hematochezia (grossly bloody stool) C. Labs: 1. CBC a. MCV <75 (microcytic) 2. Iron Studies a. Serum Ferritin b. TIBC c. Serum Iron D. Risk Factors: 1. Vegetarian 2. Gastrointestinal Disease E. Iron Food Sources: 1. Red Meat 2. Green Leafy Veggies 3. Dried Fruit 4. Nuts 5. Iron-Fortified Cereal F. Associated Symptoms: 1. Generalized Pruritis (itching) 2. Restless Leg Syndrome (crawling feeling in legs) 3. Glossitis (inflammation of tongue) 4. Angular Cheilitis (cracking at corners of mouth) G. Treatment: 1. Iron Supplement a. Iron absorption decreased 40% when taken with meals - *do not take with meals* b. Antacids or proton-pump inhibitor use will decrease iron absorption c. *Vitamin C aids in the absorption of iron - orange juice*

Pernicious Anemia (B12 Deficiency)

A. Symptoms: 1. Initial: Generalized Weakness, Paresthesias 2. Next: Leg Stiffness, Ataxia 3. Late: Memory Impairment, Personality Change, Depressed Mood B. Signs: (Mnemonic: "The 5 P's") 1. Pancytopenia (decrease in all blood cell lines) 2. Peripheral Neuropathy 3. Posterior Spinal Column Neuropathy (Dorsal Column Degeneration, Decreased proprioception, Decreased Vibration Sense, Ataxia, Hyporeflexia {e.g. Decreased Ankle Jerk}) 4. Pyramidal Tract Signs 5. Papillary Atrophy of Tongue (Atrophic Glossitis) *red, beefy tongue* C. Labs: 1. CBC a. MCV >100 (macrocytic) b. Leukopenia (decreased white blood cells) c. Thrombocytopenia (decreased platelets) 2. Serum B12 a. Megaloblastosis (oval macrocytes) D. Risk Factors: 1. Strict Vegetarian 2. History of Gastrectomy (Gastric Bypass Surgery) 3. Recent History of Malabsorption (Diarrhea) E. B12 Food Sources 1. Organ Meat a. Liver 2. Dairy Products 3. Fortified Cereal 4. Shellfish a. Clam

Liver Function Tests

Alkaline Phosphatase Serum GGT Serum AST Serum ALT

Atrophic Rhinitis

Atrophic rhinitis is a term used to describe a rare nasal infection. Although it does not have a fatal outcome, cause osteomyelitis, or produce pain, it does induce bilateral nasal obstruction and a persistent foul odor of which the subject and others are painfully aware.

Cullen's Sign

Blue discoloration from subcutaneous *ecchymosis and edema in periumbilical area*.

Nodes on Interphalangeal Joints

Bouchard's nodes are bony nodules on the proximal interphalangeal joints. Heberden's nodes are bony nodules on the distal interphalangeal joints.

Respiratory Sounds

Bronchovesicular: Vesicular:

Diplopia

Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed. Red Flags - The following findings are of particular concern: 1. More than one cranial nerve deficit 2. Pupillary involvement of any degree 3. Any neurologic symptoms or signs besides diplopia 4. Pain 5. Proptosis

Grey Turner's Sign

Discoloration at the *flank with blue-red-purple or green-brown ecchymosis*. Results from tissue catabolism of hemoglobin.

Sleep-Related Diagnostics

EMG (electromyogram) test is one that records the state of the muscle contraction when a muscle is stimulated. Other diagnostic procedures include CBC, arterial blood gases, B12 levels, and TSH level, among many. EEG is electroencephalogram. EOG is electrooculogram. PSG is polysomnogram.

Esotropia

Esotropia is in-turning of one or both eyes. It may be intermittent or constant and may occur with near fixation, distance fixation, or both. The crossing may occur predominantly with one eye or may alternate between eyes. Esotropia may occur at any age and is the opposite of exotropia (outward eye turn).

Hyperlipidemia Drug Classes

Fibrate. Niacin extended release. HMG CoA. Bile acid sequestrant.

Salter-Harris Fractures

Fractures through a growth plate; therefore, they are unique to pediatric patients. These fractures are categorized according to the involvement of the physis, metaphysis, and epiphysis. The classification of the injuries is important, because it affects patient treatment and provides clues to possible long-term complications.

Hidradenitis Suppurativa

Hidradenitis Suppurativa is a bacterial infection of the sebaceous glands of the axilla (or groin) by Gram-positive Staphylococcus aureus. It is marked by flare-ups and resolution. It can be confirmed by a C&S of the purulent discharge. I. Pathophysiology A. Inflammation of the Apocrine Sweat Glands II. Symptoms A. Pain, itching, burning and erythema in area involved III. Signs A. Characteristic 1. Early: Inflammatory Nodule or abscess 2. Later a. Sinus tract formation b. Fibrosis c. Bridge scarring d. Hypertrophic Scar or Keloid e. Contractures f. Comedones B. Distribution 1. Axilla (more common in women) 2. Anogenital area (more common in men) 3. Breasts 4. Extension onto back and buttocks IV. Management: Mild (Single Nodules with minimal pain) A. Avoid exposure to heat and humidity B. Avoid shaving if it causes irritation C. Avoid synthetic tight fitting clothes D. Use antibacterial soaps or hibiclens E. Weight loss F. Apply warm compresses to affected area V. Management: Moderate (Recurrent Nodules, pain, abscesses) A. Antibiotics for 2 months or more 1. Axillary involvement a. Dicloxacillin b. Erythromycin c. Tetracycline d. Clindamycin Topically (Cleocin-T) 2. Anogenital involvement a. Augmentin or other broad spectrum antibiotic B. Other options 1. Oral Contraceptives (high Estrogen, low androgen) 2. Accutane 0.5 to 1 mg/kg PO daily a. Used before surgery 3. Corticosteroids (variable efficacy) a. Prednisone 70 mg tapered over 14 days b. Intralesional triamcinolone 4. Cryotherapy VI. Management: Late (abscesses, sinuses, scarring) A. Referral to Dermatology B. Extensive surgical excision of lesions

Wernicke's Encephalopathy

I. Cause A. Thiamine deficiency associated with Alcoholism II. Signs A. Ataxia B. Confusion C. Internal Strabismus D. Vertical and Horizontal Nystagmus III. Complications A. Korsakoff's Disease IV. Management: Emergent Thiamine Dosing A. Start: Thiamine 50 mg IV and 50 mg IM now B. Later: Thiamine 50 mg PO or IM qd

Pancreatitis

I. Causes A. Adult common causes 1. Alcohol Abuse (35% of cases) 2. Cholelithiasis (40% of cases) II. Symptoms A. Abdominal Pain 1. Pancreatitis may be painful in some cases 2. Mid-Epigastric Pain, Left Upper Quadrant Abdominal 3. Pain or Periumbilical Abdominal Pain 4. Radiation into the chest or mid-back 5. Worse with eating and drinking (especially fatty foods) and in supine position 6. Boring pain that starts episodically and advances to become constant III. Signs A. General 1. Low Grade Fever B. Abdominal 1. Abdominal tenderness and guarding in the upper quadrants 2. Peritoneal signs may be present (e.g. abdominal rigidity or Rebound Tenderness) 3. Bowel sounds decreased 4. Palpable upper abdominal mass 5. Cullen's Sign (periumbilical discoloration with subcutaneous Ecchymosis and edema) 6. Grey Turner's Sign (flank discoloration with Ecchymosis) IV. Labs A. Approach 1. Consider obtaining Serum Amylase and serum Lipase simultaneously on initial evaluation a. *Expect Serum Amylase and Lipase to be increased in Pancreatitis* (question diagnosis if only 1 increased) b. Serum Lipase to amylase ratio >4 (and especially >5) strongly suggests Alcoholic Pancreatitis B. Fasting Triglycerides 1. *Hypertriglyceridemia (>1500)*

Subungual Hematoma

I. Causes A. Crush injury to nail II. Symptoms A. Severe, throbbing digital pain III. Signs A. Discoloration of nail B. Tip of digit swollen and tender IV. Management: *Drainage (Nail Trephination)* A. Contraindications 1. Phalanx Fracture 2. Nail Bed Laceration 3. Large Subungual Hematomas (>50% of nail) a. Requires Nail Bed Laceration suturing B. Technique 1. *Gently drill 2-3 small holes into nail* a. Number 11 blade or b. Spin 18 gauge needle between fingers or c. *Heated paper clip*

Korsakoff's Syndrome

I. Causes A. Untreated Thiamine deficiency from Alcoholism II. Pathophysiology A. Follows Wernicke's Encephalopathy B. Lesions develop in mammillary bodies and Thalamus III. Signs A. Severe Short Term Memory loss B. Intact Immediate Memory C. Confabulation IV. Management A. Thiamine (See Wernicke's Encephalopathy) V. Prognosis A. Life-long Impairment B. Improvement in 75% of patients with treatment

Allergic Rhinitis

I. Causes: Suspected Environmental Allergens A. Seasonal Allergens 1. Tree pollen (early spring) 2. Grass pollen (late spring) 3. Outdoor Molds (summer and fall) 4. Weed pollen (late summer to fall) B. Perennial 1. Dust mites 2. Animal dander 3. Irritant 4. Cigarette Smoke II. Symptoms: Specific A. Sneezing B. Rhinorrhea C. Nasal congestion D. Pruritus of the nose, eyes, and throat E. Eye Tearing and Conjunctival discharge III. Symptoms: Chronic Nasal Obstruction A. Mouth Breathing B. Snoring C. Anosmia D. Cough E. Headache F. Decreased Hearing G. Halitosis IV. Symptoms: Generalized due to chronicity of Rhinitis A. Irritability B. Fatigue C. Depression D. Malaise E. Weakness

Trochanteric Bursitis

I. Definition A. Inflammation of bursa overlying hip greater trochanter II. Symptoms A. Pain overlying greater trochanter B. May radiate into knee or ankle or into buttock C. Night pain occurs if lying on affected side D. Palliative and provocative factors 1. Worse when standing from seated or lying position 2. Improves initially on walking 3. Worse again after walking for >30 minutes III. Signs A. Point tenderness over lateral greater trochanter of hip B. Symptoms reproduced on hip adduction C. Adduction and internal rotation may also provoke IV. Management A. NSAIDs B. Modify activity C. Trochanteric Bursa Injection

Amblyopia

I. Definition A. Poor vision not correctable with eyeglasses B. No known primary cause (normal Cornea, lens, Retina) C. Greek: "Dullness of Vision"

Gastroenteritis

I. Definition: Gastroenteritis A. Inflammation of the gastrointestinal tract (Stomach and Small Intestine) B. Typical presentation is Vomiting followed by Diarrhea

Aortic Stenosis

I. Description: A. Sound B. Best Heard II. Management: A. First-Line Treatment 1. ACE Inhibitors 2. Amlodopine (Norvasc) B. Use With Caution 1. Diuretics (Lowers LV Filling Pressure) 2. Nitroglycerin 3. Beta Blockers (Increase Risk for CHF) C. Avoid 1. Peripheral Alpha Adrenergic Antagonists (Hytrin, Flomax)

Influenza

I. Epidemiology A. Annual Periodicity 1. Temperate Climate a. Onset as early as October b. Peaks in late December to March 2. Tropical Climate: Occurs year round B. Attack rate: 1. Epidemics (antigenic drift): 20-30% 2. Pandemics (antigenic shift): 50% C. Ages affected 1. Children a. Highest attack rate 2. Elderly (over age 65 years) a. Lowest attack rate b. Highest risk of complication i. Relative Risk of hospitalization: 5-10 ii. Relative Risk of mortality: 5 c. Highest mortality (80% of deaths are in elderly) D. Incidence (worldwide) 1. Severe Influenza: 3 to 5 million people annually 2. Influenza-related deaths: Up to 500,000 annually III. Course A. Incubation: 2-3 days (may be as long as 7 days) B. Infectivity (Viral load and shedding correlates with symptom severity) 1. Begins 1 day prior to symptom onset 2. Peaks with illness severity 3. Declines over 4-5 days 4. Ceases with fever resolution 5. Absent after 10 days C. Acute symptoms resolve in 4-5 days D. Persistent symptoms may not clear for 3 or more weeks 1. Fatigue or malaise 2. Persistent non-productive cough

Marfan Syndrome

I. Etiology A. Defect in gene coding for fibrillin structure B. Connective tissue defect affecting multiple systems 1. Musculoskeletal disease 2. Ocular disease 3. Cardiac disease II. Signs A. Body habitus 1. *Tall (Height exceeds 95th percentile for age)* 2. *Extremely slender build* B. Cardiovascular signs and conditions 1. Mitral Valve Prolapse 2. Aortic root dilatation 3. Myocardial Infarction 4. Aortic Insufficiency 5. Congestive Heart Failure 6. Subacute Bacterial Endocarditis 7. Aortic Dissection C. Musculoskeletal signs and conditions 1. Arachnodactyly (Spider fingers) 2. *Pectus deformity (Pigeon Breast or Funnel Breast)* 3. High narrow Palate 4. Arm Span exceeds height 5. Leg length exceeds trunk length 6. Hyperextensible joints and ligaments 7. Pes planus 8. Hammer toes 9. Vertebral Column deformities (e.g. Kyphoscoliosis) 10. Inguinal Hernia 11. Striae Distensae D. Ocular signs and conditions 1. Upward ectopia lentis 2. Myopia 3. Iridodonesis 4. Glaucoma 5. Retinal Detachment III. Labs A. Homocystinuria IV. Radiology A. Echocardiogram 1. Enlarged aortic root B. Chest XRay 1. Deformed aorta and pulmonary artery

Central Vertigo

I. Findings: Suggestive of central causes A. Nystagmus 1. Vertical or torsional Nystagmus (pure Horizontal Nystagmus may occur with either peripheral or central cause) 2. No Nystagmus on Horizontal Head Impulse Test 3. Persists <6 seconds after Dix-Hallpike Maneuver 4. Fixation of eyes on object does not inhibit Nystagmus 5. Requires weeks to months to resolve B. Episodes last hours to days C. Severe imbalance impairs standing and walking D. No Hearing Loss or Tinnitus in most central cases E. Acute Vestibular Syndrome (Posterior Circulation in 25% of cases) 1. Rapid onset (<1 hour) of acute, persistent, continuous Vertigo or Dizziness 2. Associated with Nystagmus, Nausea or Vomiting, head motion intolerance, and gait unsteadiness F. Positive HiNTs Exam Criteria (at least 1 of 3 positive) are suggestive of cerebellar CVA or Brainstem CVA (100% sensitive, 96% specific) 1. Normal Horizontal Head Impulse Test (no saccade/correction on head rotation) OR 2. Nystagmus that changes direction (or Vertical Nystagmus or torsional Nystagmus) OR 3. Skew Deviation on Alternate Eye Cover Test in which uncovered eye demonstrates quick vertical gaze corrections III. Causes: Central Vertigo A. Non-Vascular Central Causes of Vertigo (CN 8 or CNS) 1. Tumor a. Acoustic Neuroma (Vestibular Schwannoma) b. Infratentorial ependymoma c. Brainstem glioma d. Medulloblastoma e. Neurofibromatosis 2. Migraine Headache 3. Multiple Sclerosis B. Vascular disease related transient cerebral anoxia 1. Specific anoxia to vertebrobasilar system a. Vessel specific i. Brainstem Infarct (associated with Hearing Loss) 1. Anterior Inferior Cerebellar Artery Infarction 2. Anterior Vestibular Artery Infarction ii. Brainstem Infarct (no Hearing Loss) 1. Posterior Inferior Cerebellar Artery infarction 2. Labyrinthine Artery Infarction b. Precipitating conditions i. Arteriosclerosis ii. Hypertension iii. Anemia iv. Atrial Fibrillation C. Other Causes 1. Postural Hypotension 2. Syncope

Peripheral Vertigo

I. Findings: Suggestive of peripheral causes A. Pathognomonic for peripheral cause 1. Sudden onset with brief episodes often on awakening 2. Rotary Illusion with Nausea, Vomiting B. Nystagmus 1. Combined horizontal and torsional Nystagmus 2. Persists 5-20 seconds after Dix-Hallpike Maneuver 3. Fixation of eyes on object inhibits Nystagmus C. Moderate imbalance D. Nausea or Vomiting E. Associated findings 1. Hearing Loss 2. Tinnitus F. Tullio's Phenomenon 1. Nystagmus and Vertigo provoked by loud sounds II. Causes: Common (Peripheral Vertigo) A. Acute Vestibular Neuronitis B. Benign Paroxysmal Positional Vertigo C. Meniere's Disease III. Causes: Other (Peripheral Vertigo) A. Ear Infections 1. Serous Otitis Media 2. Chronic Otitis Media 3. Otitis Externa 4. Mastoiditis B. Other infections 1. Herpes Zoster Oticus (Ramsay Hunt Syndrome) 2. Acute Labyrinthitis (uncommon) a. Not synonymous with Vestibular Neuritis i. Labyrinthitis is much less common than neuritis ii. Labyrinthitis causes permanent Hearing Loss b. Types i. Viral Labyrinthitis ii. Bacterial Labyrinthitis (Rare) C. Structural disorder 1. Cholesteatoma 2. Perilymphatic Fistula 3. Otosclerosis D. Trauma 1. Temporal Bone Fracture 2. Labyrinthine Concussion

McMurray's Test

I. Indication A. Evaluation for *Knee Meniscus* Injury II. Interpretation: Positive Test Suggests Meniscal Injury A. *"Click" heard or palpated on above maneuvers*. B. Joint line tenderness on palpation.

Lachman's Test

I. Indications A. Assessment for *Anterior Cruciate Ligament (ACL)* Rupture II. Interpretation: Positive Test for ACL Rupture A. Lax endpoints on anterior translation

Gout

I. Pathophysiology A. *Gout occurs when Uric Acid levels exceed solubility limits* 1. Monosodium urate crystals deposit in joints, Kidney, and soft tissues 2. Crystal deposition triggers a inflammatory response from cytokines and Neutrophils 3. Joint space is irreversibly injured with ongoing attacks II. Risk Factors A. Most common 1. Obesity 2. Alcohol use (especially beer) 3. High purine diet (red meats, turkey and wild game, organ meats, seafood) 4. Drinks sweetened with high fructose corn syrup 5. Diuretic therapy including Thiazide Diuretics 6. Other risks a. Diabetes Mellitus b. Hyperlipidemia c. Hypertension d. Atherosclerosis e. Renal Insufficiency f. Myeloproliferative disease III. Symptoms A. Associated Symptoms 1. Chills 2. Fever as high as 104 F (40 C) 3. Severity: Very severe pain a. Unable to bear weight b. Too painful to put on socks c. Intollerant to light touch from blankets B. Regions Lower extremities 1. *First Metatarsophalangeal joint of great toe* (most common) a. Known as *Podagra* i. Affected in 50% of first gout attacks Mid-tarsal joints 2. Ankle Joints 3. Knee Joints C. Regions upper extremities 1. Fingers 2. Wrists 3. Elbows D. Characteristics: Joint Pain 1. Excruciating, crushing type pain 2. Timing: Joint Pain 3. Acute onset of lower extremity Joint Pain 4. Wakens patient from sleep IV. Signs A. Acute 1. Joint Inflammation 2. Erythema, tenderness and swelling at affected joint a. Pain extends well beyond joint b. Entire foot involved in some cases 3. Asymmetric joint involvement a. May only involve one side with the first attack 4. Skin over joint is tense and shiny B. Chronic 1. Gouty Tophi (develop after 10 years) a. Subcutaneous Nodules of monosodium urate crystals and lipids, proteins and mucopolysaccharides C. Chronic Arthritis 1. Chronic deposition occurs with recurrent attacks

Wheezing

I. Pathophysiology A. Airway wall fluttering results from flow limitation B. Expiration typically occurs passively with elastic recoil of the chest wall 1. Obstruction to outflow requires active expulsion of air 2. Resulting positive intrapleural pressure worsens the obstruction II. Causes A. Asthma

Bacterial Meningitis

I. Pathophysiology A. Cerebrospinal Fluid deficient in immune factors 1. Specific Antibody 2. Functional complement B. Inefficient phagocytosis of pathogen II. Predisposing Factors: Adults A. Recent Otitis Media or bacterial Sinusitis (25% of cases) B. Pneumonia (12% of cases) C. Immunocompromised state (16%) III. Causes A. Elderly adults 1. Streptococcus Pneumoniae 2. Escherichia coli 3. KlebsiellaPneumoniae 4. Streptococcus agalactiae (Group B Streptococcus) 5. Listeria monocytogenes B. Adults 1. Streptococcus Pneumoniae (30-50%) 2. Neisseria Meningitidis (10-35%) 3. Staphylococci (5-15%) 4. HaemophilusInfluenzae (1-3%) 5. Gram Negative Bacilli (1-10%) 6. Streptococcus species 7. Listeria monocytogenes C. Children or Infants 1. Streptococcus Pneumoniae (10-20%) 2. Neisseria Meningitidis (25-40%) 3. HaemophilusInfluenzae (40-60%) 4. Markedly reduced with Immunizations D. Neonates 1. Group B Streptococcus (49%) 2. Escherichia coli (18%) 3. Listeria monocytogenes (7%) 4. Non-Group B Streptococcus IV. Symptoms A. General 1. Fulminant onset <24 hours (25%) 2. Respiratory illness precede onset by <7 days (50%) B. Presentation in Adults and Older Children 1. Classic Triad (approaches 85% in some studies) a. Headache (87%) b. Stiff Neck (83%) c. Fever (77%) 2. Classic triad symptoms and impaired consciousness a. Virtually all Bacterial Meningitis patients have one of these symptoms b. Two of four symptoms present in 95% of patients 3. Other Presenting Symptoms a. Altered Level of Consciousness (69%) b. Vomiting (35%) c. Seizures (5%) d. Lethargy e. Irritability f. Confusion C. Newborns and Infants 1. Temperature Instability (Hypothermia or Fever) 2. Listlessness 3. Lethargy 4. Irritability 5. High pitched crying 6. Refusal to eat 7. Weak sucking response 8. Vomiting 9. Diarrhea 10. Respiratory distress 11. Bulging Fontanelle (late sign in 1/3 neonates) 12. Seizures (40%) V. Signs A. Meningeal Irritation (50% of adult patients) 1. Recent studies suggest low efficacy a. Do not rely on these signs to diagnose Meningitis 2. Nuchal Rigidity a. Unreliable in under age 18 months due to neck musculature not fully developed 3. Spinal Rigidity 4. Tests with high Test Specificity (but poor Test Sensitivity) a. Kernig's Sign b. Brudzinski's Sign B. Skin Rash Causes 1. Meningococcal Meningitis (present in 65% of Meningococcal Meningitis) 2. HaemophilusInfluenzae 3. Pneumococcal Meningitis 4. Echovirus type 9 5. Staphylococcus aureus C. Other Neurologic Signs (more common in Pneumococcal Meningitis) 1. Cranial Nerve Palsies 2. Altered Level of Consciousness 3. Focal Neurologic Signs (10-20%) 4. Seizures 5. Papilledema (3%) D. Atypical presentations (classic signs often absent in these groups) 1. Age over 65 may present with Seizures or Hemiparesis 2. Young children may present with lethargy, irritability or Seizures

Idiopathic Thrombocytopenia Purpura (ITP)

I. Pathophysiology A. IgG Antibody develops against platelet membrane antigen B. Acute Idiopathic Thrombocytopenic Purpura 1. Acute onset follows Viral Exanthem or viral Infection 2. Occurs in otherwise healthy patients C. Chronic Idiopathic Thrombocytopenic Purpura 1. Insidious onset in patient with immune disorder 2. More common onset in teenage girls II. Signs and Symptoms A. Purpura B. Bleeding complications 1. Associated with severe Thrombocytopenia (Platelet Count <30,000 per uL) C. Mild Splenomegaly in 5 to 10% of cases D. Absent signs 1. No fever, lethargy, pallor or weight loss 2. No bone or Joint Pain 3. No Lymphadenopathy 4. No Hepatomegaly III. Management: First-Line Management A. Corticosteroids 1. Indicated for severe Thrombocytopenia a. Typically indicated with Platelet Count <50,000 per uL (especially <30,000 per uL) 2. Platelets increase within a week of starting Corticosteroids 3. Dosing a. Methylprednisolone 30 ml/kg/day over 20-30 min up to 1 g/day IV OR b. Prednisone 1-1.5 mg/kg orally daily B. Intravenous Immune globulin (IV IG) 1. Dose: 1 g/kg/day for 2-3 days C. Rituximab (Rituxan) IV. Management: Emergent management A. Indications for urgent or emergent management (uncommon) 1. Serious Hemorrhage 2. Urgent or emergent surgery required B. Treatment 1. Platelet Transfusion at dosing 2-3 fold greater than usual dose

Serum Creatinine

I. Pathophysiology A. Increases by 1.0-1.5 mg/dl/day if no Renal Function B. Often unchanged until 25-50% of Renal Function lost C. Doubled Serum Creatinine implies 50% Renal Function II. Increased Serum Creatinine A. *Renal Insufficiency* B. *Decreased renal perfusion* C. Urinary Tract Infections D. Skeletal muscle Trauma or Rhabdomyolysis E. Ketonemia F. Diabetic Ketoacidosis G. Creatine Supplementation >15-20 grams per day 1. May increase Serum Creatinine over 2.0 H. Medications (Inhibit tubular secretion of Creatinine) 1. Aminoglycosides 2. Cephalosporins a. Cefoxitin b. Cephalothin 5. Hydantoin 6. Diuretics 7. Methyldopa 8. Cimetidine 9. Trimethoprim III. Decreased Serum Creatinine A. *Decreased muscle mass* B. Pregnancy

Mallory Weiss Syndrome

I. Pathophysiology A. Severe Retching results in tear in esophageal mucosa B. Lesion occurs near esophagogastric junction II. Symptoms A. Hematemesis (vomiting fresh blood) follows episode of Retching or Vomiting III. Signs A. Melena (black, tarry stool) B. Shock IV. Diagnosis A. Endoscopy (EGD) 1. Mucosal tear directly visualized V. Management A. Generally heals spontaneously within several days B. Endoscopy for cauterization if needed C. Surgery rarely required

Stridor

I. Pathophysiology A. Turbulent air flow in a partially obstructed upper airway results in a high pitched sound B. Location of obstruction determines inspiratory or biphasic timing 1. Obstruction above the glottis results in Inspiratory Stridor 2. Obstruction at or immediately below the glottis results in both inspiratory and expiratory Stridor (Biphasic Stridor) II. Causes A. Croup

Non-Dihydropyridine Calcium Channel Blocker (-zem, -mil, -dil)

I. Preparations A. Diltiazem B. Verapamil C. Bepridil II. Mechanism A. Relaxes myocardial muslce

Dihydropyridine Calcium Channel Blocker (-pine)

I. Preparations A. Nifedipine (Procardia) B. Amlodipine (Norvasc) 1. Dosing a. 2.5-5mg PO qd (MAX 10mg qd) 2. Advantages a. Does not exacerbate Left Ventricular Dysfunction C. Clevidipine D. Felodipine E. Nicardipine 1. Counters Cerebral Vessel spasm (e.g. early Subarachnoid Hemorrhage, CVA) F. Nimodipine 1. Counters Cerebral Vessel spasm (e.g. early Subarachnoid Hemorrhage, CVA) II. Adverse Effects: Peripheral Edema (Norvasc) A. Occurs more commonly in women B. Occurs more commonly on Norvasc doses >5 mg C. Adding ACE Inhibitor to regimen decreases edema III. Contraindications A. Avoid in Diabetes Mellitus (may increase Proteinuria) IV. Drug Interactions A. Clarithromycin 1. Increases Calcium Channel Blocker levels via CYP3A4 inhibition especially with Dihydropyridines and over age 65 years 2. Provokes Hypotension and Bradycardia 3. Risk of Acute Kidney Injury (often requiring hospitalization)

Rotator Cuff Injury

I. Symptoms A. Characteristics 1. Lateral arm without radiation beyond elbow 2. *Associated with arm weakness* B. Timing 1. *Night pain interferes with sleep* C. Provocative 1. Exacerbated by throwing motion 2. Overhead work II. Initial Visit A. Evaluation 1. Shoulder Exam 2. *Shoulder Xray* B. Conservative Therapy 1. Modify Activity 2. Start Physical Therapy and Encourage Early Shoulder Mobilization 3. NSAIDS

Tuberculosis

I. Transmission A. Mycobacterium tuberculosis carried in airborne droplets B. Active Pulmonary or Laryngeal Tuberculosis transmitted 1. Sneeze, cough, speak, or sing II. Symptoms A. Latent Tuberculosis is asymptomatic B. Active Tuberculosis presentation often mimics cancer presentation 1. Non-specific presentation (most common) a. Fatigue b. Weight loss c. Cachexia d. Night Sweats C. Pulmonary Tuberculosis symptoms 1. Productive cough (typically 2-3 weeks) 2. Hemoptysis (uncommon) 3. Pleuritic Chest Pain 4. Dyspnea III. Signs A. Sites of Involvement 1. Primary infection: lung involvement B. Disseminated Disease IV. Management A. Latent Tuberculosis 1. Positive PPD without signs of Active Tb 2. Treatment indicated if risk of Tb Progression from latent to active disease B. Active Tuberculosis

Mild Punishments for Bad Behavior

Logical consequences, which would include time-outs, work best with children 3 years - 8 years. Distraction works best with infants and toddlers. Natural consequences is most effective for ages 9 and above. Loss of privileges works best with adolescents.

Jarisch-Herxheimer Reaction

Most patients with primary or secondary syphilis, especially those with secondary syphilis, have a JHR within 6 to 12 h of initial treatment. It typically manifests as malaise, fever, headache, sweating, rigors, anxiety, or a temporary exacerbation of the syphilitic lesions. The mechanism is not understood, and JHR may be misdiagnosed as an allergic reaction. JHR usually subsides within 24 h and poses no danger. However, patients with general paresis or a high CSF cell count may have a more serious reaction, including seizures or strokes, and should be warned and observed accordingly. Unanticipated JHR may occur if patients with undiagnosed syphilis are given antitreponemal antibiotics for other infections.

Fosamax

Patients taking aledronate are instructed to take the medication when they get up in the morning, 30 minutes before eating and with a full glass of water. They should be instructed to remain upright to avoid esophageal irritation. If they take this medication with food, it will reduce the bioavailability by 40%. Taking alendronate with coffee or orange juice will reduce bioavailabiliy by 60%.

Antidysarrthymic Classes

Procainamide - Class IA Mexiletine - Class IB Propafenone - Class IC Amiodarone - Class III

Proptosis (Exophthalmos)

Proptosis is protrusion of the eyeball. Exophthalmos means the same thing, and this term is usually used when describing proptosis due to Graves disease. Disorders that may cause changes in the appearance of the face and eyes that resemble proptosis but are not include hyperthyroidism without infiltrative eye disease, Cushing disease, and severe obesity. Red Flags - The following findings are of particular concern: 1. Eye pain or redness 2. Headache 3. Loss of vision 4. Diplopia 5. Fever 6. Pulsating proptosis 7. Neonatal proptosis

Reflex Grades

Reflexes are graded on a scale of 0 (no response) to 4+ (very brisk response). A normal or average response is graded as 2+.

Strabismus

Strabismus is misalignment of the eyes, which causes deviation from the parallelism of normal gaze. Diagnosis is clinical, including observation of the corneal light reflex and use of a cover test. Treatment may include correction of visual impairment with patching and corrective lenses, alignment by corrective lenses, and surgical repair. Strabismus occurs in about 3% of children. Left untreated, about 50% of children with strabismus have some visual loss due to amblyopia.

Tumors

T0 - No evidence of primary tumor. T1 - Tumor 2 cm or less in greatest dimension. T2 - Tumor more than 2 cm but no more than 5 cm in greatest dimension. T3 - Tumor more than 5 cm in greatest dimension.

Salter-Harris Fracture Type II

The *most common* type of Salter-Harris fracture, a type II fracture occurs through the physis and metaphysis; the epiphysis is not involved in the injury. These fractures may cause minimal shortening; however, the injuries rarely result in functional limitations.

Hyperlipidemia Medications

The expected outcomes of the preceding medications are as follows: Lipitor: LDL: 20-60% decrease HDL: 5-15% increase Triglyceride: 10-40% decrease Gemfibrozil: LDL: 5-15% decrease HDL: 14-20% increase Triglyceride: 20-50% decrease Nicotinic acid: LDL: 10-25% decrease HDL: 15-35% increase Triglyceride: 20-50% decrease Colestipol: LDL: 10-20% decrease HDL: 3-5% increase Triglyceride: May increase

Infant Reflexes

The fencing reflex (tonic neck reflex) is done by turning the head to one side with the jaw over the shoulder. This should cause the arm and leg on the side where the head is turned to extend and the arm and leg on the opposite side to flex. I. Reflexes A. Foot 1. Stroke Inner Sole (Grasp) a. Toes curl around ("grasp") examiner's finger 2. Stroke Outer Sole (Babinski) a. Toes spread, great toe dorsiflexion B. Walking Reflex 1. Hold baby up with one hand across chest 2. As feet touch ground, baby makes walking motion ("stepping") C. Rooting Reflex 1. Touch newborn on either side of cheek 2. Baby turns to find Breast 3. Sucking Mechanism on finger is divided into 3 steps: a. Front of Tongue laps on finger b. Back of Tongue massages middle of the finger c. Esophagus pulls on tip of finger D. Tonic Neck (Fencing) Reflex 1. If the Babies' head is rotated leftward a. The left arm (face side) stretches into extension b. The right arm flexes up above head 2. Opposite reaction if head is rotated rightward E. Moro Reflex (Startle Reflex) 1. Hold supine infant by arms a few inches above bed a. Gently drop infant back to elicit startle 2. Baby throws Arms out in extension and baby grimaces F. Hand-to-Mouth (Babkin) Reflex 1. Stroke newborns cheek or put finger in babies palm 2. Baby will bring his fist to mouth and suck a finger G. Swimmer's (Gallant) Response 1. Hold baby prone while supporting belly with hand a. Stroke along one side of babies' spine 2. Baby flexes whole body toward the stroked side

Koplik Spots

They are small, white spots (often on a reddened background) that occur on the inside of the cheeks early in the course of *measles*.

Spontaneous Abortions

When there is vaginal bleeding and cramping but the cervix remains closed it is a threatened abortion. It is possible in this case that the pregnancy can be salvaged. In an inevitable abortion the cervix is dilated. In a complete abortion the placenta and fetus are expelled completely. In an incomplete abortion placental products remain in the uterus and the cervix remains dilated.