NURG 602 test 1

Fakuda step test

*Procedure*: Patient marches in place, eyes closed for 50 steps *Positive*: a turning to one side >30 degrees *Indicates*: vestibular lesion on the side of rotation

Subconjunctival hemorrhage: Risk Factors

-Age -Contact lens wearer -Systemic diseases -Bleeding disorders -Recent cataract surgery -Active lifestyle/hobbies

CAD/CHD

-Caused by atherosclerosis of coronary arteries -Narrowing of vessels, plaque rupture, and thrombus = ↓ O2 and blood flow to heart -May result in: MI, sudden unexpected death, angina, arrhythmias, and heart failure

Ocular Foreign body: Differentials

-Corneal abrasion, infection, herpetic ulcer, keratitis, INTRAocular foreign body

Risk factors for hordeolum and chalazion

-Poor eyelid hygiene -Wearing contact lenses -Applying makeup -Blepharitis -Rosacea

CAD: Lifestyle Modification

-Treat co-morbidities: HTN, DM, Hyperlipidemia, obesity -Smoking cessation -Low fat diet

Stable angina

-pain < 15 minutes - substernal heaviness or pressure; no change in frequency, severity of duration of anginal symptoms in past 6 weeks -Predictable with exertion or anxiety; relieved by rest or NTG•

What important health promotion and disease prevention education is important to share with a person who has COPD

Avoid tobacco products, environmental exposure, immunizations, influenza vaccination for all pneumococcal vaccinations.

Risk reduction for ALL COPD patients

Avoidance of all tobacco smoke •Smoking cessation and second hand smoke avoidance •Discuss at every visit! Avoid environmental exposure •Reduce personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants. Immunizations •Influenza vaccination for all •Pneumococcal vaccinations •PCV13 and PPSV23 for all patients ≥ 65 yrs •PPSV23 for younger COPD patients with significant comorbid conditions - especially cardiac.

Aspirin for ASCVD prevention

B recommendation - USPSTF •Initiate low-dose (81 mg) aspirin use for the primary prevention of cardiovascular disease and colorectal cancer •Adults aged 50 to 59 years who have -a 10% or greater 10-year CVD risk -are not at increased risk for bleeding -have a life expectancy of at least 10 years -are willing to take low-dose aspirin daily for at least 10 years

Pharmacological therapy for Bacterial conjunctivitis

Bacterial (non-STI) •Antibiotic drops or ointment for 5-7 days •Erythromycin 5 mg/gram ophthalmic ointment0.5-inch QID •Trimethoprim-polymyxin B 0.1%-10,000 units/mL ophthalmic drops 1 to 2 drops QID •Bacitracin 500 units/gram OR Bacitracin-polymyxin B 500 units-10,000 units/gram ophthalmic ointment, 0.5 inch 4 to 6 times daily •Ofloxacin 0.3% OR Ciprofloxacin 0.3% (preferred agents in contact lens wearers to cover pseudomonas)1 to 2 drops QID •Azithromycin 1% ophthalmic drops1 drop twice a day for 2 days; then 1 drop daily for 5 days Bacterial (STI related) •Gonococcal - may give Rocephin IM and refer immediately to evaluate cornea •Chlamydial - Doxycycline 100 mg BID x 3 weeks

Which beta blockers are cardiac selective in low doses?

Beta 1 receptors: atenolol, bisoprolol, metoprolol, nebivolol

Centor Criteria for GABHS

1 point each •Fever > 38 ̊ C (100.4 ̊ F) •Tender anterior cervical adenopathy •Lack of cough •Pharyngotonsillar exudate Modified/McIsaac •Age 3-14 +1 •Age 15-44 0 •Age > 44 -1

Clinician/patient discussion surrounding HLD

10 year and lifetime ASCVD risk Risk enhancing factors Coronary Artery Calcium Score Lifestyle habits Realistic potential for lifestyle modification Statin intensity and potential benefit Potential for adverse effects Potential for drug interactions Therapy cost Patient preferences and values

Stage 2 HTN, avg BP > 20/10 mm above target Initiation with

2 first-line agents of different classes

If PEF drops below _________ of personal best, follow the asthma action plan and check PEF frequently that day.

80%

What is the BP treatment goal SBP/DBP for virtually all adults?

<130/80

cough

A PHYSIOLOGIC REFLEX TO PROTECT AIRWAYS BY CLEARING SECRETIONS AND FOREIGN PARTICLES

Which classes of drugs are most effective in delaying progression of kidney disease in those with CKD?

ACE OR ARB.

Hordeolum (Stye)

ACUTE inflammation or infection of the eyelid margin involving the sebaceous gland of an eyelash or meibomian gland

ACE inhibitors have a common side effect of dry cough. What class of medication can be substituted with similar MOA and reduced potential for side effects?

ARB

Cough; Diagnostic studies

Acute •CXR if has dyspnea or pneumonia suspected •Pulse oximetry or ABGs •Spirometry Chronic •CXR •Nasopharyngeal swab for pertussis •Sinus imaging•PFTs/spirometry •Barium swallow, esophageal pH/EGD •Gram stain if cough productive

SABA examples

Albuterol (Proventil, Ventolin, ProAir) - MDI or nebulizer Levalbuterol (Xopenex) - MDI or nebulizer

Renin Inhibitors

Aliskiren MOA •Action at the beginning of the RAA cycle reducing levels of angiotensin I and II •Very long acting •Effective for BP reduction, reduction of albuminuria, limiting LV hypertrophy Adverse effects •Hypotension and kidney injury if given in patients with bilateral RA stenosis •Risk of hyperkalemia, especially patients with CKD or on K+ sparing drugs •Contraindicated in pregnancy No trial data establishing impact on CV events/mortality

According to the updated 2019 guidelines, what antimicrobial therapy is first line for individuals WITHOUT risk factors?

Amoxicillin 1g three times daily (strong recommendation, moderate quality of evidence)

Severe eye pain is associated with what ocular diagnoses?

Angle-closure glaucoma

superficial thrombophlebitis assessment, dx, and tx

Assessment •Swelling, tenderness, redness along the course of vein(s) •Greater saphenous vein most often involved •Fever •Firm cord along vein Dx •No specific diagnostics unless sepsis is a concern or icondition is recurrent Tx •Removal of catheter if applicable •Local heat and extremity elevation •NSAIDs •Antibiotic if infection

What lab value is sensitive for changes in patients with congestive heart failure?

B type Natriuretic Peptide (BNP)

community acquired pneumonia- typical causative organisms

Bacteria: -Streptococcous pneumoniae -Mycoplasma pneumoniae (cough transmitted, seen in those who spend time close proximity to others) -Hemophilus influenzae (most common in tobacco users) -Legionella species (spread through contaminated water/mist source such as a/c, pool, or spa) Viruses - Influenza types A and B, adenovirus, respiratory syncytial virus, coronavirus and parainfluenza

Which class of medication frequently causes peripheral edema as a side effect? Would a diuretic be effective in reducing this?

CCB No, but ACE or ARB may help

dyspnea on exertion, clear frothy sputum--consider

CHF

Chalazion

CHRONIC inflammation from obstructed Zeis or meibomanian gland

Which two beta blockers are unique in that they have peripheral action as well as cardiac?

Carvedilol and nebivolol

Pharyngitis/tonsillitis assessment: Virus

Cough, cold, rhinorrhea Hoarse, lack of exudate Conjunctivitis

Individuals with what chronic disease may benefit from these ACEs/ARBs?

DM, CKD, heart failure, or reduced EF.

What medication should and should not be prescribed in uncomplicated corneal abrasion?

DO NOT USE topical steroids *Should give ofloxacin, ciprofloxacin, sulfacetamide, erythromycin, polymyxin B/ trimethoprim

Beta blockers

Decrease HR and contractility which will ↓ cardiac O2 requirements Demonstrated to prolong life in patients with CAD post MI Consider as first line therapy with chronic angina

What population may present with silent ischemia?

Diabetics or past MI

What is the gold standard for detection of mononucleosis

EBV antibody titer

WHY DOES CHOLESTEROL MATTER?

Essential structural component of membranes •maintenance of correct permeability, fluidity, and outer layer of plasma lipoproteins. •precursor to corticosteroids, sex hormones, bile acids, and vitamin D. Risk for Atherosclerotic Cardiovascular Disease (ASCVD) •Coronary heart disease •Stroke •Peripheral artery disease

Lipid management for Primary Prevention: Age 40-75, LDL-C levels 70-189 mg/dL

Estimate 10-year ASCVD risk •Intermediate risk - Moderate intensity statin - - Goal: ≥ 30% LDL-C reduction •High risk - goal of 50% LDL-C reduction Risk enhancing factors present •initiate or intensify statin Borderline/intermediate risk -CAC score •CAC score of zero - reasonable to withhold statin •CAC score of 1-99 - reasonable to initiate statin for patients 55 or older •CAC score of 100 or higher - initiate statin

What medications have been associated with increased blood pressure?

Estrogen, Oral Contraceptives, chronic NSAID use, pseudoephedrine/decongestant use, Illicit drugs, diet supplements.

Ocular foreign body: Etiology and Risk factors

Etiology •Accidental trauma •Dust, dirt, metal, glass, etc. Risk factors •Lack of protective eyewear •Hobby or work environment

Why is amoxicillin (with or without clavulanate) recommended as first line treatment of bacterial rhinosinusitis over fluoroquinolones?

Greater adverse events with fluoroquinolones

Duration of abx therapy for CAP

Guided by a validated measure of clinical stability •resolution of VS abnormalities (HR, RR, BP, O2 sat, temp) •ability to eat •normal mentation Continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence)

What heparin type is preferred as initial treatment of DVT and PE due to predictable pharmacokinetics? What is the method of administration?

IV heparin LMWH SQ

superficial thrombophlebitis etiology

IV therapy Venous trauma Bacterial infections

Management of hearing loss

Identify Etiology •Refer if etiology unclear Treat underlying etiology •Infection •Remove cerumen •Discontinue ototoxic meds •ENT/Surgical consult Adaptive measures •Hearing aids •Sign language / lip-reading •Use "good" ear

With what medication must long-acting beta agonists be combined in asthma treatment?

Inhaled Corticosteroids

Once dyslipidemia is identified, what lab values should be drawn, and perhaps undergo further evaluation and treatment before moving on to statin treatment?

Liver function tests, HgbA1C, apolipoprotein B (apoB), Lipoprotein a- (Lp(a)

Systolic dysfunction: decreased contractility

Low ejection fraction Often the result of CHD or MI S3 often heard

Lipid follow up

Measure fasting lipids -4-12 weeks after med initiation or dose adjustment -every 3-12 months to assess adherence or safety Encourage lifestyle changes Evaluate for -New onset DM -Liver function -Muscle complaints -ASCVD

What type patients are on lifetime anticoagulation?

Mechanical heart valve

Vertigo: Treatment

Meniere Syndrome o Low salt diet and diuretics o Meclizine for sx relief of acute vertigo attacks Benign Paroxysmal Positional/Positioning Vertigo o MRI for recurrent cases o Epley maneuver

What antihypertensives have central action, and may result in sedation?

Methyldopa, Clonidine, Guanabenz, Guanfacine

What is the cause of angina

Myocardial oxygen demand is > myocardial oxygen supply CHD, emboli, coronary vasospasm, severe aortic disease, increased metabolic demands (exercise, stress, cold exposure, hyperthyroid, anemia, large meal), rapid ventricular rates •Printzmetal's angina: caused by coronary artery spasms

With what atypical presentation might women with myocardial ischemia present?

New onset fatigue or SOB Jaw, neck, arm or back pain without chest pain

DVT risk factors

Obesity Orthopedic surgery Immobility Trauma Pregnancy or estrogen use Malignancy Coagulation defects Venous catheters Rheumatoid disease Lupus High altitude Polycythemia vera

Pharynx: red flags

Peritonsillar abscess

Discussion and evaluation related to statin safety

Proactive discussion and evaluation Net clinical benefit Potential for ASCVD risk reduction vs. statin associated side effects Statin-drug interactions Predisposing factors for statin-associated side effects -DM risk -Baseline muscle symptoms and conditions -Baseline hepatic panel -Potential for pregnancy, breastfeeding

Long term controller meds in asthma: Long - acting beta2 agonists (LABA)

Provide bronchodilation for up to 12 hrs after single dose ◦Not used as monotherapy - no anti-inflammatory effects ◦Not used as acute treatment - up to 1 hour for effect

Anti-cholinergic/muscarinic

Provides additive benefit to SABA in moderate or severe exacerbations in the acute care setting Typically not used in monotherapy for asthma Examples: ◦Ipratropium (Atrovent) -MDI or nebulizer (alone or mixed with albuterol) ◦Ipratropium/albuterol combination (Combivent)

Beta 2 agonists: MOA

Rapid relaxation airway smooth muscle

Routine f/u in asthma

Routine follow up (3-6 month) with evaluation of control and possible step down in treatment

· What medication class is considered most important in ASCVD risk reduction related to lipid therapy?

Statins (HMG-CoA Reductase Inhib)

Long term controller meds in asthma: Methylxanthines

Theophylline ◦Provides mild bronchodilation, enhances mucus clearance, strengthens diaphragmatic contractility ◦Useful as adjunct therapy in nocturnal asthma ◦Narrow therapeutic index ◦Numerous drug interactions

What class of medication may increase uric acid and potentiate gout flares?

Thiazide diuretics

What medication classes should be used cautiously individuals with glaucoma?

With caution -Adrenergic agents, antipsychotics, antidepressants, anticholinergics No- decongestants or motion sickness meds.

What medication class is first line treatment for COPD?

Bronchodilators

Managing Out-Patient COPD Exacerbations

Bronchodilators •Inhaled SABA/LABA +/- inhaled anticholinergic ABX •Increased sputum purulence and either increased dyspnea or sputum volume Systemic glucocorticoids •Shorten recovery time, improve lung function and hypoxemia •Oral prednisolone 30-40 mg/d for 7-10 days is recommended Controlled O2 therapy •Indicated in patients with hypoxia, with the aim of improving oxygen saturation to 88- 92% •Use nasal prongs at 0.5-2.0 L/min. •Minimize excessive O2 administration Supportive therapy •Fluid, nutrition, smoking cessation, treat co-morbidities

Once diagnosis is confirmed, severity of airflow limitation is classified by

By % of predicted FEV1

How is ASCVD risk calculated and why? What is the percentage for low, borderline, intermediate and high risk?

By lab and taking history. Utilize the primary prevention chart. and/or ASCVD calculator: Low: <5% Borderline: 5-<7.5% Intermediate risk: ≥7.5-<20% High risk: 20% or greater.

In regard to Aphthous Ulcers, large or persistent areas may require

biopsy

Glaucoma

optic neuropathy (nerve damage) leads to progressive, irreversible vision loss frequently associated with increased intraocular pressure (IOP)

DM and smoking predisposes for

otitis media

Hib vaccine decreases occurrence of what for children

otitis media (per lecture) * also epiglottitis

Most common cause of COPD exacerbation

viral or bacterial respiratory tract infection

COPD exacerbation risk increases with

•Worsening airflow limitation •FEV1 < 50 % of predicted value •Previous treated events •Two or more exacerbations within the last year

Environmental and Personal health strategies for those with asthma

◦Minimize environmental exposure ◦Avoid tobacco smoke, air pollution, fires, including wood burning fireplaces and stoves ◦Use of air purifier especially near open windows during pollen seasons ◦Individualize recommendations for aerobics in cold weather and during peak pollen counts.

Certain signs and symptoms (fever, cough, tachycardia, rales) are common among patients with CAP, but differential diagnoses may include:

CHF with pulmonary edema, Pulmonary embolism, Atelectasis, Aspiration or chemical pneumonitis, Lung cancer, Acute exacerbation of bronchiectasis, Interstitial lung diseases (eg, sarcoidosis, asbestosis, hypersensitivity pneumonitis, cryptogenic organizing pneumonia), Acute exacerbations of COPD, Influenza and other respiratory viral infections, Acute bronchitis, Asthma exacerbations

Meds during acute asthma attack

"Rescue drugs"- Short acting Beta2 agonist (SABA) ◦Albuterol or Levalbuterol by MDI or nebulizer ◦Every 20 minutes x 3, then every 1-4 hrs as needed ◦Ipratroprium in addition to SABA - not used first line ◦Oral corticosteroids--40-80 mg po- may need to continue for 7-10 days

Persistent cough

(3-8 weeks) Consider pertussis, post infectious cough, ACE-inhibitors

Acute cough

(< 3 weeks) Usually due to viral respiratory infections

Chronic cough

(> 8 weeks) Most common causes are Asthma, GERD, and Postnasal drip However consider: COPD, Smoker, Lung cancer, CHF

How would you evaluate an individual for suspected rhabdomyolysis?

(CK, CR, UA for myoglobinuria), check hepatic panel

Certain x-ray findings suggest certain causes of pneumonia, but radiographic appearance alone cannot reliably differentiate among etiologies.

(lobar consolidation - typical bacterial pathogens)

Which classes of drugs are first line for the treatment of HTN in most individuals?

*Thiazide diuretics CCBs, ACE/ARB

Secondary causes of elevated LDL

- Diet high in saturated or tans fats - Weight gain - Anorexia - Biliary obstruction - Nephrotic syndrome - Hypothyroidism - Obesity - Pregnancy - Meds s/a •Diuretics •Cyclosporine •Glucocorticoids •amiodarone

When evaluating effectiveness of LDL reduction, what values would you evaluate?

- If high intensity: 50% or more from baseline - Moderate intensity: 30% or more from baseline

Bronchopneumonia

- affecting the bronchi or alveoli

interstitial pneumonia

- affecting the interstitial tissue

lobar pneumonia

- confined to a lobe

Mild persistent asthma- Step 2

- either daily low-dose ICS and as-needed SABA or intermittent as-needed SABA and ICS used one after the other -Individuals with low or high perception of symptoms may not be good candidates for as-needed ICS therapy

Long-acting muscarinic antagonists (anticholinergics) are NOT recommended as add on therapy in

- not recommended in place of LABA - not recommended in individuals with glaucoma or at risk for urinary retention

What are potential complications of the flu?

- secondary bacterial infections (sinusitis, otitis) - Pneumonia - Exacerbation of underlying pulmonary or cardiac conditions

Consult/Refer to Ophthalmologist for blepharitis IF

- treatment failure - may require surgical meibomian gland drainage or extraction - Additional symptoms - Spread of infection to conjunctiva or cornea

Diagnosing TB

-(+) PPD is not indicative of active disease, but the person has been infected with the organism at some point -Chest X-ray: Infiltrates depending on stage of disease -THREE morning sputum samples for stain and culture: + Acid-fast bacilli (AFB) is suspicious of TB -Bronchoscopy: If negative for AFB but still suspicious. Unable to produce voluntary sputum -Definitive diagnosis: (+) sputum culture with M tuberculosis

HEENT: Physical Assessment

-Assess entire EENT system with any EENT complaint -Cranial nerve involvement -Lymphadenopathy -Assess non-affected side first (so you know what normal looks like) -Consider comorbidities ( -Visual acuity with eye complaints

What diagnostic labs and/or tests are completed in hypertensive individuals, and why?

-Basic: fasting blood glucose, CBC, lipid profile, serum creatinine with eGFR, serum sodium, potassium and calcium, TSH, urinalysis, electrocardiogram -Optional: echocardiogram, uric acid, urinary albumin to creatinine ratio

Asthma Pathophysiology

-Bronchial constriction in response to exposure to triggers due to tightening of surrounding smooth muscle. -Mucosal edema results from inflammatory mediator activation/ cell infiltration. a. Epithelial damage--basement membrane thickening b. Structural changes include hypertrophy and hyperplasia of smooth muscular tissue as well as tissue fibrosis/scarring as part of remodeling -Goblet cell hyperplasia, increased mucous production -Inflamed airways are more hyperreactive, and will be more prone to bronchospasm

Major risk factors for ASCVD in addition to elevated LDL-c

-CIGARETTE SMOKING -HYPERTENSION -DYSGLYCEMIA -ADVANCING AGE -OTHER LIPOPROTEIN ABNORMALITIES

Relatively fixed risk factors for HTN

-CKD -Family history -Increased age -Low socioeconomic/educational status -Male sex -Obstructive sleep apnea -Psychosocial stress

COPD: Pathophysiology:

-Can cause fibrosis at the bronchial lining -Hypertrophy of smooth muscle cells -Breakdown of alveolar walls -Honeycomb to balloon stimulation of goblet cells to produce more mucus.

Evaluation of hearing loss

-Cerumen impaction -Otitis Media -Otitis Externa -Foreign body -Tympanic perforation -Concussion

Dietary recommendations per AHA guidelines

-Cholesterol lowering of ~ 5-10% depend on baseline diet -Caloric adjustment to achieve/maintain healthy weight • Reduce -Animal products and Sugar -Meat, Dairy, Eggs, Butter, Lard, sugar sweetened beverages or foods with added sugar -Percentage of calories from saturated (5-6%) or trans fat • Increase -Foods high in fiber - Fruits, Vegetables, Legumes, Whole Grains -Omega-3 Fatty Acids - Fish: salmon & tuna, Canola oil -Consider soluble fiber & plant stanols/sterols

Ocular foreign body: Physical Assessment

-Comprehensive eye exam - visual acuity, inspect outer eye, outer and inner aspects of upper and lower eyelids (evert for better visualization, check pupillary response, assess EOMs, perform fundoscopic exam -Fluorescein staining detect defects on epithelial lining *Findings vary...but may include quiet eye (no tearing, discharge, injection or edema), or dark specks on iris, or "rust ring" at site of entry, or diffuse injection, or abrasion or tear of epithelial layer

Modifiable risk factors for HTN

-Current cigarette smoking, secondhand smoking -Diabetes mellitus -Dyslipidemia/hypercholesterolemia -Overweight/obesiy -Physical inactivity/low fitness -Unhealthy diet

Common presenting symptoms--May be asymptomatic early in the disease

-Dyspnea -Chronic Cough -Acute worsening of symptoms -Chronic sputum production

Identify the body systems/target organs that should always be examined when a patient is diagnosed with HTN. What specific physical findings might be observed in patients with uncontrolled HTN?

-Eye- Retinopathy -Brain- Hemorrhage, TIA/Stroke, vascular dementia -Blood vessels- PVD -Kidneys- Renal failure -Heart- Left ventricular hypertrophy, heart failure, coronary heart disease

Risk factors for CAD

-Family history (younger onset in 1st degree relative = higher risk) -Advanced age, Male gender, postmenopausal female -Dyslipidemia -Diabetes mellitus -Hypertension -Abdominal obesity -Cigarette smoking -Sedentary lifestyle, excess alcohol, few fruits & vegetables -Metabolic syndrome •Abdominal obesity, TG > 150 mg/dL, HDL < 40 mg/dL in men; < 50 mg/dL in women, fasting glucose ≥ 110 mg/dL, HTN

Blepharitis: Differentials

-HSV of eyelid may appear similar to staphylococcus blepharitis but has more acute onset -Chalazion, hordeolum, conjunctivitis and keratitis may result from blepharitis -Sebaceous cell carcinoma of eyelid - typically unilateral and should be considered if no response to treatment within 1 month

Blepharitis: Risk Factors

-Hx of skin problems - seborrheic or contact dermatitis, acne rosacea, dry eye syndrome -Poor hygiene - improper cleaning of face, using old/contaminated eye make-up -Contact lens use -Immunocompromise (Chemo/DM/HIV)

ACUTE BRONCHITIS: common presenting symptoms:

-Hyperreactive bronchioles, initially dry cough, then productive cough worse at night with mucopurulent sputum -Afebrile or low grade temp, malaise, fatigue, headache, chest burning, substernal pain, occasional dyspnea, wheezing. Purulent nasal secretions, Cervical lymphadenopathy. Respiratory wheezes or rhonchi (may clear with cough) Tachycardia. No lung consolidation symptoms

HEENT: assessing PMH

-Incidence and frequency of URIs -History of antibiotic use -EENT surgeries -Major medical conditions -Medications -Immunizations -Prior diagnostic tests

Cholesteatoma

-Initial retraction of TM creating squamous epithelium-lined sac which may become infected and enlarge -A result of chronic OM -Slowly erodes bone and can cause hearing loss, balance problems, CN VII paralysis, meningitis, brain abscess from slow erosion into brain cavity -IMMEDIATE REFERRAL to ENT -Requires surgical removal

OBVIOUS STATIN BENEFIT GROUPS

-LDL >/= 190 -DM -ASCVD

RISK DISCUSSION FOR PRIMARY PREVENTION EVERY 4-6 YEARS FOR AGES 20 AND OLDER

-Lifetime estimated ASCVD risk ages 20-39 •Low < 39% •High 39% or higher -10 year estimated ASCVD risk age 40+ •Low (< 5%) •Borderline (5 - < 7.5%) •Intermediate (≥ 7.5 - < 20%) •High (≥ 20%) -Presence of Major Risk Factors -Presence of Risk Enhancers -Coronary Artery Calcium score in some

Additional labs to draw when evaluating lipids

-Liver Function tests if statins may be considered -Hgb A1C if DM status unknown -Apolipoprotein B - apoB if Triglycerides ≥ 200 mg/dL •ApoB level ≥ 130 mg/dL or persistent elevation constitutes risk-enhancing factor -Lipoprotein a - Lp(a) with family history of premature ASCVD or personal history of ASCVD not explained by major risk factors •Lp(a) ≥ 50 mg/dL may be a risk enhancing factor •In women, the risk is considered enhanced only in the presence of hypercholesterolemia

bacterial rhinosinusitis: Presentation

-Nasal obstruction or congestion with erythematous mucosa -PURULENT nasal drainage -Facial pain or pressure with tenderness on palpation -Altered sense of smell -May have tooth pain and/or headache -Sore throat worse in morning, better after eating/drinking - Post Nasal Drip -Possibly: Fever, malaise, fatigue, halitosis, nausea

HEENT: Diagnostics

-Not always necessary -POC tests are helpful in narrowing differentials -Ordered based on presentation

Alpha-1 antitrypsin therapy in COPD management

-Not recommended for COPD that is unrelated to alpha-1 antitrypsin deficiency

Mucolytics in COPD management

-Overall benefits are very small but may be useful in patients with viscous sputum -Maintain adequate systemic hydration -Consider cough training, postural drainage, or chest physiotherapy

Ocular foreign body: Hx taking and symptoms

-Pain, foreign body sensation -Photophobia -Tearing, red eye -History of timing, setting

Angina/ischemia less likely (but be aware for atypical!) if:

-Prolonged duration of chest pain (hours/days) -Shooting knifelike pain at apex or over precordium -Pain worsens with respiration or MSK movement -Localized chest wall tenderness

HEENT: assessing social hx

-Recreation -Occupation -Smoking -Drugs -Home environment -Dental care

What is ciliary flush and what are the implications for the patient?

-Redness concentrated directly around the iris. -Infectious keratitis, iritis, and angle-closure glaucoma. -Can cause vision loss * Immediate referral

What education should be provided to CHF patients and their families?

-Regular moderate exercise or cardiac rehab as tolerated -NSAIDs contraindicated-Salt restriction - DASH diet; abstinence from alcohol-Compression stockings prn -Pt/family should assess weight gain on DAILY basis, same time each day •1 lb/day x 3 or 3 lbs in 1 day concerning

subconjunctival hemorrhage: Etiology

-Rupture of conjunctival blood vessel causes bright red, sharply delineated area surrounded by normal appearing conjunctiva -Spontaneous -Minimal trauma -Improper contact lens placement/cleaning -Hypertension - most common cause in patients > 60 years of age -Disease (atherosclerotic disease, DM, bleeding factors) -Valsalva maneuvers (coughing, sneezing, straining, vomiting)

What factors are considered when determining whether patients need basic or expanded antimicrobial coverage?

-S. Pneumoniae -chronic heart disease -chronic lung disease, liver, renal disease, DM, alcoholism, malignancies, asplenia, immunosuppressive illness, use of antimicrobials within previous 3 months, exposure to child who attends day care center

Hordeolum and Chalazion: Differentials

-Sebaceous cell carcinoma -Trauma -Blepharitis -Dacryocystitis -Periorbital cellulitis

Blepharitis: etiology

-Seborrheic- sebaceous gland dysfunction with accelerated shedding of skin cells -Infectious - most likely staph aureus

Strongly consider angina if:

-Substernal pain with radiation to shoulders, neck, jaw, arms, epigastrium and possibly upper back -Pain is deep and intense, but not excruciating. -Often described as pressure , tightness, heaviness -Duration of pain is minutes (not seconds or days) -Pain is precipitated by exercise or emotional stress -Pain is relieved by rest or taking sublingual NTG -Atypical presentation in elderly, women and diabetics

bacterial rhinosinusitis: etiology

-Typically begins when a viral URI extends into the paranasal sinuses and become infected with bacteria. -May result from impaired mucociliary clearance and/or obstruction of the sinus pore

Consult/Referral to ophthalmologist for hordeolum/chalazion IF

-Unresponsive to treatment -Chalazion causing cosmetic concern -Orbital cellulitis (ophthalmoplegia, pain with eye movements, and proptosisis) a medical emergency

Exercise-Induced Bronchospasm

-Usually begin during exercise or within 3 minutes after its end -reaches peak within 10-15 minutes after stopping exercise, resolves within 60 minutes

Acute bronchitis: typical causative organisms

-Viruses (rhinovirus, coronavirus, adenovirus, influenza) -Bacteria (bordatella pertussis, s. pneumoniae, h. influenzae)

Secondary causes of elevated TGs

-Weight gain -Very low fat diets -High intake of refined CHO -Excessive alcohol intake - Nephrotic syndrome - Chronic renal failure - Lipodystrophies - Diabetes - poorly controlled - Hypothyroidism - Obesity - Pregnancy -meds s/a •Oral estrogens. •Glucocorticoids •Bile acid sequestrants •Protease inhibitors •Retinoic acid •Anabolic steroids •Sirolimus •Raloxifene •Tamoxifen •Beta blockers (except Carvedilol) •Thiazides

What nonpharmacological interventions should be instituted with all patients whose BP is elevated or hypertensive?

-Weight loss- 1 mmHg reduction for every 1 kg in body weight -Heart healthy diet- DASH diet- rich in fruits, veggies, whole grains, low fat dairy, reduced saturated & total fat -Sodium reduction- <1500 mg/d optimal. At least 100 mg/d reduction for most adults -Potassium supplementation if not contraindicated- 3500-5000 mg/d in diet -Structured increase in phys activity -Alcohol restriction- Men-2 drinks/day, women 1 drink/day. (12oz beer, 5oz wine, 1.5 oz spirits)

Unstable angina

-recent onset or change in severity, frequency or duration of symptoms and may occur at rest or nocturnally -911 or hospital immediately

Long-acting muscarinic antagonists (anticholinergics) recommendations as add-on therapy

-to ICS if LABA cannot be used -to ICS-LABA combination if asthma is uncontrolled

At what point in TB treatment should sputum cultures return negative?

3 months

Once the INR is stable, what is the longest interval until it needs to be repeated?

4-6 weeks if stable INR/ dosing

Glaucoma: screening eye exam starting at age ______ biannually; sooner if high risk IOP screening after age 65

40

When initiating warfarin therapy, how long should parenteral anticoagulation be continued in order to ensure steady state and appropriate anticoagulation effects?

5 days

Strep pharyngitis typically lasts___________ with fever peaking at day 2-3. May return to school/work after 24 hours fever free

5-7 days

Angina is the classic symptom of CAD. Usually not symptomatic until _________% blockage. Intervention at ______% or greater

50-70%; 70%

When would a repeat lipid profile be drawn after initiating or changing the dose?

6-8 weeks, check LFT's at baseline

In individuals with SBP in the 130-139/80-89 range, what factor determines whether they should be started on antihypertensive medications?

< 10% clinical ASCVD 10 year risk Nonpharmacologic therapy Reassess in 3-6 months ≥ 10% clinical ASCVD 10 year risk OR clinical CVD Nonpharmacologic therapy BP lowering medication Reassess 1 month

In what patient population would malignancy be a high priority differential when presenting with a single enlarged cervical lymph node?

>40 yo Gradual onset and enlargement, non-tender, firm, matted, no infection present

Does a positive PPD indicate active TB disease?

A positive PPD doesn't indicate an active disease, but the person has been infected with the organism at some point

Additional diagnostic testing in COPD patients

ABGs •in patients with FEV1 <40% predicted •if hypoxemia or hypercapnia is suspected •Clinical signs suggestive of respiratory or RH failure •central cyanosis, ankle swelling, JVD CXR •May be useful to exclude differential diagnoses EKG/Echo •Arrhythmias, right heart failure, pulmonary HTN Alpha-1 antitrypsin deficiency screening •Patients who develop COPD younger than 45 or have FH

Which classes of antihypertensives should NEVER be used together in the same patient and are contraindicated in individuals who are pregnant or who have bilateral renal artery stenosis?

ACE-I, ARB, renin inhibitors

Conjunctivitis AKA: Pink Eye

Acute Inflammation of Palpebral and or Bulbar Conjunctiva

What conditions constitute "clinical ASCVD"?

Acute coronary Syndromes, Hx of MI, Stable or Unstable Angina, Coronary Revascularization, Stroke, TIA presumed to be of atherosclerotic origin, Peripheral Arterial Disease, Hx of Peripheral Arterial Revascularization, aortic aneurysm

Follow up on asthma exacerbation

Acute exacerbation •F/U in 24 hrs, then 3-5 days, then weekly until symptoms are controlled and PEF >80% consistently •Follow monthly until stabilized

Definition of Community-acquired pneumonia

Acute infection of the lung, may include parenchyma, alveolar spaces, and/or interstitial tissue. In a community dwelling patient (not residents of nursing homes or other long-term care facilities) May also be diagnosed in previously ambulatory patient within 48 hours of admission to the hospital

Acute Bronchitis

Acute inflammation of the lining of the tracheo-bronchial tree associated with cough and mucus production but no lower airway consolidation

Pertussis

Acute respiratory infection caused by Bordetella pertussis

TB treatment principles

Administer multiple medications to which the organisms are susceptible Add at least 2 new anti-TB agents to regimen when treatment failure is suspected Provide the safest, most effective therapy in the shortest period of time Ensure adherence to therapy (major cause of treatment failure) Treat by clinicians skilled in management of TB

Physical activity recommendations per AHA guidelines

Aerobic activity • Moderate to vigorous intensity • 3-4 sessions per week • Average of 40 minutes per session •May reduce LDL-C on average 3-6 mg/dL

WHO IS AFFECTED BY ASTHMA?

Affects approximately 5% of population Slightly more common in male children (< 14 yrs) and female adults Occurs at all ages, with approximately ½ of all cases developing during childhood and another 1/3 before age 40. A genetic predisposition is recognized ATOPY is strongest identifiable predisposing factor Obesity is an increasingly recognized risk factor

Meds contributing to HTN

Alcohol - Limit alcohol to ≤1 drink daily for women and ≤2 drinks for men. Amphetamines - Discontinue or decrease dose; consider behavioral therapies for ADHD Antidepressants (e.g., MAOIs, SNRIs, TCAs) - Consider alternative agents (e.g., SSRIs) depending on indication. -Avoid tyramine-containing foods with MAOIs Caffeine - Limit caffeine intake to <300 mg/d and avoid use in patients with uncontrolled HTN. -Associated with acute BP increase; long-term use not associated with increased BP/CVD Decongestants(e.g., phenylephrine, pseudoephedrine) -Use for shortest duration possible, and avoid in severe or uncontrolled HTN -Consider alternative therapies (nasal saline, intranasal corticosteroids, antihistamines) Oral contraceptives -Use low-dose agents, progestin-only contraception, or alternative forms of birth control -Avoid use in women with uncontrolled hypertension NSAIDs - Avoid systemic NSAIDs when possible; Consider alternative analgesics Systemic corticosteroids - Avoid or limit use; consider alternative administration modes Herbal supplements, Recreational drugs, Immunosuppressants (cyclosporine), Atypical antipsychotics (clozapine, olanzapine), Angiogenesis inhibitor (bevacizumab) and tyrosine kinase inhibitors (sunitinib, sorafenif)

What adults should receive an annual flu vaccine?

All adults aged 18 or older, including pregnant women. Patients aged >65 should have high dose trivalent inactivated vaccine Contraindicated in patients with hx anaphylactic reaction to vaccine.

Which class of antihypertensive may also be helpful in relieving symptoms of BPH?

Alpha-Adrenoreceptor Antagonists. -end in "azosin" common: prazosin, terazosin, doxazosin

Other ways to measure BP

Ambulatory BP monitoring (ABPM) •Generally accepted as the best out-of-office measurement method •Obtain out-of-office BP readings at set intervals, every 15- 30 mins throughout the day and every 15 mins - 1 hour during the night usually over a 24 hour period •Conducted while individuals go about their normal daily activities •Uses: a) provide estimates of mean BP over entire monitoring period & separately during nighttime and daytime b) determine daytime-to-nighttime BP ratio to identify extent of nocturnal "dipping," c) identify early-morning BP surge pattern, d) estimate BP variability e) allow recognition of symptomatic hypotension. Home BP monitoring (HBPM) •Often a more practical approach in clinical practice •Used to obtain a record of out-of-office BP readings taken by a patient. •Patients/caregivers need training to increase accuracy

Extended spectrum penicillin therapy in CAP

Amoxicillin-clavulanate (Augmentin) - Regular dose 875 mg BID, High dose 2 gm BID Dose based on amoxicillin, using the highest strength tablet available for the dose. Most amoxicillin tablets have the same dose of clavulanic acid despite the strength, and doubling tablets can cause excess clavulanic acid resulting in diarrhea Clavulanic acid prevents destruction of amoxicillin from beta lactamase producing pathogens

What is included in an asthma education plan?

An asthma education plan will include your medicines and instructions for what to do when you are feeling well, what to do when you have asthma symptoms and what to do when your asthma symptoms are getting worse. It should include the names of your medicines, how much to take and when to take it.

Education for Flu

Annual flu vaccine unless contraindicated, transmission, isolation/hygiene measures. Transmission precautions should remain in place until 7 days from symptoms onset or until 24h from symptom resolution-- whichever is longer

Uveitis: Acute intraocular Inflammation of components of uveal tract

Anterior: iris (Iritis),ciliary body - about 90% of patients with uveitis Intermediate -structures posterior to the lens (pars planitis or peripheral uveitis) Posterior: choroid, retina or vitreous

What is the difference in antiplatelet and anticoagulant therapy? Which one requires that the clinician monitors INR values? What types of patients would require anticoagulant, rather than antiplatelet therapy?

Anti-platelets prevent platelet aggregation. Anticoagulants inhibit synthesis of clotting factors. Warfarin requires monitoring. Reasons for anticoagulation include: Afib, DVT, PE, mechanical heart valve

Causes of CP: Psychogenic disorders

Anxiety Panic Disorder Depression **Pain or pressure, SOB, dizziness. Often associated with specific event or time

obstructive sleep apnea (OSA): Common presenting symptoms:

Arterial htn, excessive somnolence, morning sluggishness, headache, daytime fatigue, cognitive impairment, weight gain, impotence, loud cyclic snoring, breath cessation, witnessed apnea, restlessness, and thrashing during sleep

Causes of CP: Thyroid

Assess for goiter and abnormal thyroid labs Hypothyroidism •Bradycardia, mild hypotension, dyspnea, swollen extremities Hyperthyroidism •Anxiety, tachycardia, arrhythmia, systolic flow murmurs, palpitations, dyspnea

What difference in pathophysiology of COPD and asthma?

Asthma is earlier onset and usually allergy mediated with reversible airflow limitation; whereas COPD is later onset and mostly due to cumulative irritant exposure with progressive symptoms and irreversible airflow limitation related to airway remodeling.

ACS

Atheromatous plaque disruption resulting in clot formation or vasospasm in coronary arteries result in myocardial ischemia and cardiac muscle damage Immediate Referral to ER - needs cardiology & cath lab (reperfusion) -Labs show: ↑ troponin which is best marker of cardiac damage; ↑ CK-MB -EKG may show elevation or depression of ST segment; Q waves

Non-pharmacologic therapy for Conjunctivitis

COOL MOIST COMPRESSES UP TO QID - DISPOSABLE IF VIRAL OR BACTERIAL DISCARD CONTACTS AND EYE MAKEUP - NO USE UNTIL RESOLVED AVOID IRRITANTS AND RUBBING EYES GOOD HYGIENE - HANDWASHING, CLEAN LINENS

•Persistent cough with phlegm--consider

COPD

When to refer COPD patients to pulmonology

COPD stages moderate to very severe Onset before age of 40 Frequent exacerbations (>2/yr) despite optimal treatment Rapidly progressive COPD Symptoms disproportionate to severity of airflow obstruction Need for long term oxygen therapy Co-morbid illnesses

What disease processes and causative organisms can produce a complaint of cough in a patient?

COPD, CHF, GERD, TB, Lung Cancer, Asthma, Postnasal drip/ Allergic Rhinitis, Sinusitis pneumonia, bronchitis, hyperactive airway

Venous thrombosis differentials

Cellulitis Ruptured synovial cyst (Baker's cyst) Lymphedema Musculoskeletal strain Acute arterial occlusion

Stepwise approach for management of asthma

Check adherence • Step up if needed; reassess in 2-6 weeks • Step down if possible (if asthma is well controlled for at least 3 consecutive months) •Consider consult with asthma specialist at Step 3 and consult if Step 4 or higher is required.

How would you decide whether to work up a patient with a chest complaint as an inpatient or outpatient?

Chest pain, pressure, heaviness for >20 minutes unrelieved by rest or NTG. Typical MI symptoms

CAP basis for diagnosis

Chest x-ray is the gold standard for diagnosis of pneumonia

Ears: Red flags

Cholesteatoma •"cauliflowerlike" growth and foul-smelling ear discharge Basilar skull fracture •Battle sign - bruise behind ear over mastoid & recent trauma) •Golden fluid discharge from nose/ear

Moderate COPD (class II) symptoms

Chronic cough and sputum production. Dyspnea with everyday exertion

Mild COPD (class I) symptoms

Chronic cough, sputum production but may be intermittent

Very severe COPD (class IV) symptoms

Chronic cough, sputum production. Complications such as respiratory and/or heart failure begin to develop. Quality of life is extremely impaired and the symptoms become life threatening.

Severe COPD (class III) symptoms

Chronic cough, sputum production. Dyspnea occurs after minimal exertion, Small tasks like leaving the house or going upstairs are a major issue

What are the treatment principles for chronic atrial fibrillation?

Chronic: Rate control, anticoagulation therapy, antiarrhythmics Acute: cardioversion (with anticoagulation if Afib <48 hours)

Causes of CP: Drug induced

Cocaine Severe, sharp pressure-like or squeezing substernal pain •May see euphoria, paranoia, delusions, followed by depression, N/V, muscle twitching •Complications- hypertensive crisis, coronary artery vasospasm, arrhythmias

Outpatient CAP treatment per 2019 IDSA/ATS CAP Guidelines Patient WITH co-morbidities chronic heart, lung, liver, or renal disease; DM; alcoholism; malignancy; asplenia or risk factors for antibiotic resistant pathogens

Combination therapy Amoxicillin/clavulanate: 500 mg/125 mg TID, 875 mg/125 mg BID, 2000 mg/125 mg BID OR Cephalosporin: (cefpodoxime 200 mg BID or cefuroxime 500 mg BID AND a macrolide: (azithromycin 500 mg on 1st day then 250 mg daily, clarithromycin [500 mg BID or ER 1000 mg QD) OR doxycycline 100 mg BID (pregnancy cat. D) Monotherapy respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg, daily, or gemifloxacin 320 mg daily)

ARBs

Common ARBs •candesartan, irbesartan, losartan, olmesartan, valsartan •Many in combination with HCTZ and CCB MOA •Block Angiotensin II receptors rather than prevent conversion Adverse effects •Hypotension and kidney injury if given in patients with bilateral RA stenosis •Risk of hyperkalemia, especially patients with CKD or on K+ sparing drugs Contraindicated in pregnancy Alternative to ACE-I •If angioedema with ACE-I, may trial ARB 6 weeks after discontinuation of ACE-I •Good alternative if cough occurs with ACEI Do NOT use in combination with ACE-I or renin inhibitor

Alpha-Adrenoceptor Antagonists

Common Alpha blockers •Prazosin, terazosin, doxazosin MOA •Blocks post-synaptic alpha receptors which relax smooth muscle, and decrease BP by lowering peripheral vascular resistance •Short term relief of obstructive prostatic symptoms Adverse effects •Orthostatic hypotension in older adults •Marked hypotension, palpitations, headache, nervousness, syncope •Anticholinergic effects •No adverse side effects on serum lipids Not first line for HTN

Beta blockers

Common BBs •Atenolol, bisoprolol, metoprolol, propanolol, labetalol •Carvedilol (Coreg), nebivolol (Bystolic) MOA: •Decrease HR, CO, renin release - cardioprotective •Block beta receptors - some selective •B1 receptors -cardiac; B2 receptors- bronchi, vasculature; At higher doses, all BB are nonselective •Carvedilol and nebivolol also reduce PVR through alpha blockade and increased nitric oxide release Side effects •MAY induce/exacerbate bronchospasm (asthma/COPD) •Sinus or AV node depression (block or bradycardia) •Nasal congestion, fatigue, lethargy •Raynaud phenomenon or symptoms in patients with PVD •Erectile dysfunction •Traditional BB have adverse effect on lipids and glucose metabolism and can mask symptoms of hypoglycemia Not used first line for HTN; consider as addition if concomitant CAD, stable CHF

CCBs

Common CCB •Amlodipine, felodipine, nicardipine, nifedipine (dihydropyridine agents) •Diltiazem and verapamil (non-DHP agents)•often used for angina; reduce cardiac conduction and contractility more MOA •Cause peripheral vasodilation •Typically faster BP reduction Adverse effects •Most notable - potential for peripheral edema •Dose low and increase slowly •Combination with ACEI or ARB may reduce edema •Headache, bradycardia, constipation CAUTIOUS use in patients with cardiac muscle dysfunction •Amlodipine is safest choice

Drugs with Central Sympatholytic Action

Common drugs •Methyldopa - used for HTN in pregnancy •Clonidine - patches can be helpful in patients who have compliance issues with pills •Guanabenz •Guanfacine - long acting MOA •Stimulation of alpha adrenergic receptors in the CNS, reducing peripheral sympathetic outflow Adverse effects •Sedation, fatigue, dry mouth, postural hypotension, ED •Rebound hypertension with discontinuation

ACE inhibitors

Commonly ACE-I: •benazepril, captopril, enalapril, fosinopril, lisinopril •Many in combination with HCTZ MOA •Prevent conversion of angiotensin I to II, inhibit bradykinin degradation, stimulation of synthesis of vasodilating prostaglandins, decrease sympathetic nervous system activity •Beneficial with chronic kidney disease and heart failure Few adverse effects •Most notable - dry COUGH (10%) •Hypotension and kidney injury if given in patients with bilateral RA stenosis •Angioedema - most severe s/e •Risk of hyperkalemia, especially patients with CKD or on K+-sparing drugs CONTRAINDICATED in pregnancy Do NOT use in combination with ARB or renin inhibitor

Thiazide type Diuretics

Commonly used •HCTZ: 12.5 or 25 mg daily •Chlorthalidone: 12.5 or 25 mg daily •Indapamide: 2.5 mg daily •Metolazone 12.5- or 25 mg daily MOA •Initially - decrease plasma volume •Long term- reduce peripheral vascular resistance Good monotherapy in many individuals •Chlorthalidone is preferred due to prolonged half-life and proven trial reduction of CVD Potential for metabolic changes •↓ potassium, ↓ magnesium, ↓ sodium, ↑ calcium, ↑ glucose, ↑ LDL ↑ TG •May increase uric acid and potentiates gout flares •Minimal potential for ED, skin rash, photosensitivity Avoid evening dosing if possible

In a 48 year old male with acute onset fever of 101 F for 24 hours, productive cough of yellow/green sputum, rapid flu and COVID negative, and x-ray as presented, what is the diagnosis?

Community acquired pneumonia

Principles with resistant HTN

Confirm accurate BP measurements Assess for nonadherence with prescribed regimen Identify and reverse contributing lifestyle factors Discontinue or minimize interfering substances Screen for secondary causes of hypertension Pharmacologic treatment Refer to appropriate specialist

Respiratory causes of CP

Consider -Pulmonary Embolism, Pleurisy, Pneumonia -Spontaneous pneumothorax or hemothorax •acute unilateral, stabbing pain with dyspnea

Otitis Externa: Prevention

Consider with recurrent OE, swimmers, immunocompromised, dermatology conditions effecting the ear. Avoid water in the ears -Ear plugs, blow dry the ear (low setting 12 in away from the ears), drops containing alcohol and/or acetic acid Regularly remove and clean anything inserted in the ear (hearing aids, ear buds, phones, etc.)

Fluorescein eye staining is used when the NP is looking for what type of problems?

Corneal abrasion Foreign body

subconjunctive hemorrhage: differentials

Corneal abrasion, foreign body, penetrating trauma, hyphema

Keratitis:

Corneal inflammation or infection - vision threatening

Musculoskeletal causes of chest pain

Costochondritis •Common form of inflammation of the cartilage where ribs attach to the sternum (anterior costochondral junction) •Can involve multiple cartilage areas bilaterally, but is usually only on one side Tietze Syndrome •Tenderness and swelling over the ribs and cartilage near the sternum. •Redness and heat can also be present, but a localized swelling is the distinguishing finding •Pain is variable, often sharp, and can last from hours to weeks •CRP and sed rate may be elevated

What is a post infectious cough and what are treatment options for it?

Cough lasting 3-8 weeks following acute respiratory infection. Tx options: Short term ipratropium, nighttime antitussives, or steroids

Cardiac labs

Creatine kinase isoenzyme (CK-MB) Cardiac Troponin I and T •Markers of cardiac myocyte necrosis •Troponin more sensitive & specific than CK-MB •Both positive as early as 4-6 hrs after onset of MI; abnormal by 8-12 hrs •CK-MB normalizes within 24 hrs •Troponin elevated for 5-7 days High sensitivity C-reactive protein (hs-CRP) •Detect inflammatory process caused by atherosclerosis B type Natriuretic Peptide (BNP) •Expressed in ventricles, elevated when filling pressures are high •Sensitive in patients with symptomatic heart failure •Less specific in older patients, women, patients with COPD

You diagnose an otherwise healthy 48 yo male with community acquired pneumonia. He is an acceptable outpatient treatment candidate and is allergic to macrolides. Which of the following is the most appropriate treatment for him? A. Azithromycin B. Ciprofloxacin C. Levofloxacin D. Amoxicillin

D. PREFERRED: Amoxicillin 1000 mg TID Other options to consider: Doxycycline 100 mg BIDA macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg BID or clarithromycin extended release 1,000 mg daily) only in areas with pneumococcal resistance to macrolides < 25%- but NOT for this patient because he is allergic to macrolides!

According to the updated 2019 guidelines, what antimicrobial therapy is first line for individuals WITH co-morbidities/risk factors? How does this therapy differ from those without risk factors?

Depends on whether combination therapy or monotherapy: Combination therapy- Augmentin or Cephalosporin AND macrolide or doxycycline Monotherapy- respiratory fluoroquinolone

CHF

Determine etiology of failure - should be followed by cardiology Testing: BNP, CBC, electrolytes, ECG, CXR, ECHO**** Treatment dependent upon etiology, acute or chronic -Diuretic therapy - first line •Mild CHF - thiazides or similar (HCTZ, metalozone, chlorthalidone) •More severe - loop diuretic (furosemide, bumetanide, torsemide •K+ sparing (triamterene, amiloride, spironolactone) used in combination with other diuretics •Monitor K+ -Renin-angiotensin-aldosterone system inhibitors - first line •ACE inhibitors or Angiotensin II receptor blockers (ARBs) -Beta blockers - typically add early in treatment •Control elevation of catecholamine & SNS activity• •Can increase EF up to 10% -Implantable defibrillator (EF ≤ 35%) or biventricular pacing Patient Education -Regular moderate exercise or cardiac rehab as tolerated -NSAIDs contraindicated -Salt restriction - DASH diet; abstinence from alcohol -Compression stockings prn -Pt/family should assess weight gain on DAILY basis, same time each day•1 lb/day x 3 or 3 lbs in 1 day concerning

Mitral stenosis murmur

Diastolic: Left lateral decubitus position, rumbling, low

What are possible secondary causes of LDL > 190?

Diet- saturated or trans fats, weight gain, anorexia Drugs-diuretics, cyclosporine, glucocorticoids, amiodarone Diseases-biliary obstruction, nephrotic syndrome Disorders and altered states of metabolism- hypothyroidism, obesity, pregnancy

Which CCBs are used for BP control rather than rate control?

Dihydropyridine agents: Amlodipine, Felodipine, Nicardipine and Nifedipine.

Pertussis disease course

Disease course typically lasts ~ 6 weeks -Catarrhal stage: insidious onset with malaise, hacking cough, sneezing moves to Paroxysmal stage: bursts of rapid consecutive coughs followed by deep high-pitched inspiration (whoop) over 4 weeks -Convalescent stage: decrease in frequency and severity of paroxysms of cough

What are the first line treatments in CHF?

Diuretic therapy and RAAS inhibitors (ACE/ARB) ** for diuretics Mild CHF - thiazides or similar (HCTZ, metalozone, chlorthalidone) More severe - loop diuretic (furosemide, bumetanide, torsemide K+ sparing (triamterene, amiloride, spironolactone) used in combination with other diuretics-Monitor potassium level

General principles of HTN therapy

Dosing antihypertensive medication once daily rather than multiple times daily is beneficial to improve adherence. Use of combination pills rather than free individual components can be useful to improve adherence to antihypertensive therapy. With new or intensified treatment, schedule monthly follow-up evaluation for adherence and response to treatment until BP control is achieved. Simultaneous use of an ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful and not recommended to treat HTN.

Doxycycline in CAP

Doxycycline 100mg BID •Pregnancy category D (DON'T!!) •Very inexpensive and can be attractive option if patient has financial issues. •Can produce photosensitivity with sun exposure. •Can cause esophageal irritation - take with plenty of fluid

Cerumen Impaction

Dry or Moist Cerumen Excess or Impaction -Excessive cerumen production -Inappropriate EAC cleaning -Environmental or grooming substances -Hearing aids, ear plugs, ear buds Removal if symptomatic or need to fully visualize TM -SX: hearing loss, fullness, pressure, itching, pain, irritation of EAC

Varicose veins dx and tx

Dx •Duplex ultrasound Tx •Compression stockings •Leg elevation when possible •Weight loss if applicable •Refer for ablation or sclerotherapy interventions

Which test can provide intervention to correct conduction abnormalities?

EPS/ablation

In regards to asthma, HYGIENE THEORY is speculative, but worth noting

Early exposure to daycare; rural environment; early exposure to animals ◦Favor immune responses away from allergy development Antibiotic use; Western lifestyle ◦Favor immune responses towards allergy responses

How is the suspected diagnosis of Mitral Valve Prolapse confirmed?

Echocardiogram

Which cardiac diagnostic test best provides information related to cardiac structure, and ventricular and valve function?

Echocardiography

Which cardiac tests evaluate the electrical conduction of the heart?

Electrocardiography

Cardiac complaints: Diagnostic testing

Electrocardiography •Electrical conduction •Rate, rhythm, ST changes, possible chamber enlargement, conduction abnormalities •Ambulatory - Holter/Event monitor Echocardiography •Ultrasound to create images of cardiac anatomy •Transesophageal echo (TEE) - high resolution images of posterior heart •Chamber size, ventricular function (EF), valve integrity, anatomic abnormality Nuclear myocardial perfusion imaging •Injection of tracer radioactive elements •Can be done at rest and with stress (pharmacologic or exercise) •Thallium or technetium tracer concentration ↓ in areas of reduced blood flow •Defect resolves - viable tissue •Fixed Defect - myocardial scar •Newly positive test needs coronary angiography to further evaluate Chest xray CT •Coronary artery calcium MRI •Aortic dissection, pericardial thickening, LV mass Positron Emission Tomography (PET) •Tracers emitting two photons •Improved spatial resolution •Used for perfusion studies, myocardial viability Stress testing •Standard treadmill/bicycle with ECG monitoring Cardiac Catheterization (Coronary Angiography) •Identify coronary artery disease, catheter based intervention •Hemodynamic measurements Electrophysiology testing •Catheter delivered electrodes induce rhythm disorders •Ablation

Empirical therapy for cough

Eliminate irritant exposure and increase air humidification •Discontinue ACE inhibitors •Treat likely causes ●Postnasal drip - Antihistamines, decongestants, nasal steroids ●Asthma - SABA, Treat according to severity ●GERD - PPI and Therapeutic lifestyle changes ●Post-infectious cough - if impacting QOL use short term ipratropium, nighttime antitussives, or steroids •REFER if not responsive to empiric therapy, has alarm or recurrent symptoms

Basic abx coverage in CAP:

Empiric regimens cover the most common bacterial cause of CAP in the outpatient setting (S. pneumoniae) and atypical pathogens

Asthma --common presenting symptoms

Episodic wheezing, Recurrent chest tightness, Recurrent Dyspnea, Chronic Dry or Spasmodic Cough Symptoms can range for mild to severe

Otitis Externa

Erythema, edema, and/or infection of EAC Common etiologies •Recent water exposure •Mechanical trauma to EAC skin •Localized infected hair follicle •Most common bacteria: Staph Aureus, Pseudomonas Aeruginosa •Fungal infections secondary to prolonged Otic antibiotic use •Eczematous conditions: Seborrheic dermatitis, atopic dermatitis, psoriasis •Immunocompromised

How does secondary HTN differ from essential HTN?

Essential is due to complex interactions b/w multiple genetic and environmental factors. Secondary HTN happens BECAUSE of another issue - meds, OSA, etc (see above list). Think if there has been a sudden spike in HTN, they're young, no family history... consider if it is a secondary cause. If there is a secondary cause you may be able to eliminate that factor and avoid putting them on a medication

PAD

Etiology •Acute thrombus leading to embolus •Chronic atherosclerotic lesions •Inflammatory component of arteries •Trauma or entrapment Risk Factors •Age > 40 •Tobacco usage •Hyperlipidemia, HTN, atherosclerosis, DM •obesity

Chronic Venous Insufficiency (CVI)

Etiology •Venous backflow valves become incompetent and blood is regurgitated through the valves resulting in engorgement and secondary edema of the lower leg(s) Prevention •Weight loss •Avoid prolonged standing and immobility •Compression stockings for high risk patients •Early aggressive treatment of thrombophlebitis

Acute Otitis Media: Etiology

Eustachian tube obstruction → accumulation of fluid and mucus → secondary bacterial infection (S. pneumonia, H. influenza)

Should statins be discontinued in individuals older than 75 years of age? Why or why not? This should be a conversation with the patient with consideration for:

Evaluate potential ASCVD risk reduction, adverse effects, drug-drug interactions, patient frailty, patient preferences LDL-C of 70-189 mg/dL -May initiate moderate intensity statin Clinical ASCVD -Initiate or continue moderate to high intensity statin Diabetes -Continue statin therapy if tolerated

CHOLESTEROL SYNTHESIS AND REDUCTION

Exogenous pathway (Dietary)- Approximately 10 % Endogenous synthesis (Liver)- Approximately 90%

Treatment of persistent, severe, or complicated bacterial rhinosinusitis--->

FIRST LINE: Amoxicillin w/ or w/o clavulanate 5-10 days (High Dose if DRSP risk) Greater adverse events with fluoroquinolones than amoxicillin If PCN allergy: Doxycycline, levofloxacin, moxifloxacin If using Bactrim DS or macrolides, consider drug resistance in your area

What are the limitations of a rapid monospot test? What lab test would provide definitive information regarding the patient's Epstein Barr Virus status?

False negative early is disease. about 25% false negative in first week. EBV antibody titer is gold standard

AOM management: Abx

First line: Amoxicillin -Dose, frequency and duration based on severity of disease, recent antibiotic use -500 - 875 mg BID or TID; 5-10 day treatment -Amoxicillin-clavulanate covers H. influenzae With AOM and acute RM rupture -Combination of oral and topical (fluoroquinolone) antibiotics and prevention of water entry into the ear PCN allergy without type 1 hypersensitivity reaction (urticaria or anaphylaxis) -Cefdinir, Cefpodoxime, Cefuroxime, Ceftriaxone (2 g IM once) Severe PCN allergy -Macrolide: Erythromycin plus sulfonamide; azithromycin; clarithromycin -Trimethoprim-sulfamethoxazole in regions where pneumococcal resistance is not a concern. -Consider drug resistance in your area If treatment failure after 2 - 3 days use alternative agent -Amoxicillin-Clavulanate , Cefuroxime axetil, or Ceftriaxone

What is the DOC (drug of choice) in the treatment of AOM? What is the DOC for AOM in penicillin allergic patients?

First line: Amoxicillin Dose, frequency and duration based on severity of disease, recent antibiotic use 500 - 875 mg BID or TID; 5-10 day treatment Amoxicillin-clavulanate covers H. influenzae PCN allergy without type 1 hypersensitivity reaction (urticaria or anaphylaxis) Cefdinir, Cefpodoxime, Cefuroxime, Ceftriaxone (2 g IM once) Severe PCN allergy Macrolide: Erythromycin plus sulfonamide; azithromycin; clarithromycin Trimethoprim-sulfamethoxazole in regions where pneumococcal resistance is not a concern. Consider drug resistance in your area

When should individuals with a corneal abrasion be seen for follow-up?

Follow up daily until resolved, typically 24-48 hours for simple abrasions.

Acute bronchitis: pertinent education:

Follow up if no improvement or symptoms worsen after 72 hours. Typically, recovery in 7-14 days. Cough may last several weeks. Symptoms and duration may be worse in smokers. Monitor for complication such as pneumonia. Refer to pulmonologist if no improvement in 4-6 weeks or having more severe symptoms.

When should inhaled corticosteroids be used for COPD treatment? What about systemic corticosteroids?

For COPD patients with FEV1 <60% predicted, ICS improves symptoms, lung function, quality of life, and reduces frequency of exacerbations. Once patient is group C or D. COPD is not generally responsive to oral corticosteroids and are not recommended for long term tx of COPD.

Ranexa

For chronic angina •Can cause QT prolongation; no effect on HR or BP •Safe to use with ED drugs

Cervical adenitis: Management

For localized infection •Warm compresses for 15 mins QID •OTC analgesics •Resolves within 2-3 weeks

Pulmonary rehabilitation for COPD patients

For low risk patients with more symptoms and all high risk COPD patients Goal: reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities A comprehensive pulmonary rehabilitation program -Includes exercise training, nutrition counseling, and education -Is a minimum of 6 weeks; Longer programs produce more effective results -Identifies baseline and outcome measures to quantify individual gains and areas for improvement

When should chemoprophylaxis for influenza be considered?

For people at increased risk for complications from infection who are exposed to an infected patient within 2 weeks of vaccination, for persons unlikely to respond to vaccination because of immunosuppression after exposure to an infected person

Long term controlled meds in asthma: Oral Corticosteroids

For severe persistent asthma ◦7.5-60 mg every other day or daily ◦use lowest dose possible due to s/e ◦Short course bursts to achieve control or during exacerbation High dose corticosteroid therapy may produce s/e: adrenal suppression, osteoporosis, skin thinning, easy bruising, cataracts For postmenopausal women ◦Concurrent Calcium 1000-1500 mg/Vitamin D 800 iu daily supplementation, consider bisphosphonate therapy Monitor patients on long term corticosteroid therapy ◦Periodic eye exam ◦Bone mineral density testing

In individuals >75, discontinue statin for:

Functional decline, multimorbidity, frailty or reduced life-expectancy limits potential benefits of statin therapy

Substernal burning, indigestion, regurgitation, hoarseness, choking, bitter taste-- consider

GERD

What are common differential diagnoses for chest pain and how each may be distinguished from angina.

GERD Esophageal spasm, Electrolyte disorders Drug induced(cocaine) MI MVP Resp. illness Angina Cholecystitis Anxiety/ panic attack Herpes zoster Musculoskeletal Arrhythmias Thyroid disorder Dissecting aortic aneurysm

What are the most common side effects of bile acid sequestrants?

GI symptoms: constipation and gas. Interferes with fat soluble Vit A,D, E, K May increase serum TG levels; avoid if TG >300mg/dL

Pharyngitis/tonsillitis assessment: Diphtheria

Gray pseudomembrane

Oral candidiasis: Differential diagnosis

Hairy leukoplakia, Lichen planus, geographic tongue, exudative pharyngitis

Audiometric studies for hearing loss

Hearing loss without obvious pathology needs immediate audiometric referral Routine audiologic screening may be indicated due to environmental exposure and in those age 65 and older

Epistaxis

Hemorrgage •From nostrils, nasopharynx, or nasal cavity

What is a hyphema and what is the recommended course of action on presentation?

Hemorrhage (gross visible blood) into the anterior chamber of the eye. *Immediate transport to ER or ophthalmologist, minimize eye movement, non-pressure eye patch keep patient up right, limit activity

Eyes: red flags

Herpes Keratitis •eye pain, photophobia, blurred vision Acute Angle-closure glaucoma •eye pain, N/V, HA, halos around lights, cloudy cornea Acute vision loss

Causes of CP: Nerve

Herpes Zoster •pain along dermatomes •vesicular rash •More common in elderly & immunosuppressed Nerve root compression •pain , motor, and sensory deficits •numbness/tingling in neck, chest, upper arm

Seasonal Influenza

Highly contagious virus transmitted by respiratory route Strains vary year to year Annual epidemics typically in fall or winter Incubation period 1-4 days

Vertigo: Hx and Physical Exam

History •Onset - sudden, gradual •Duration - seconds, minutes, hours, days •Associated symptoms - HA, tinnitus, hearing loss •Medications •Co-morbidities Physical Exam •Ears - anatomy and function •Vision screening •Nystagmus - Dix-Hallpike •Cranial Nerves •Cardiovascular - rhythm, bruits

What is the difference in etiology of a hordeolum and a chalazion? Which one may require antibiotic treatment?

Hordeolum (stye)- Typically, pyogenic (typically staphylococcal) infection or abscess Chalazion- Noninfectious obstruction causing extravasation of irritating lipid material in the eyelid soft tissues with focal secondary granulomatous inflammation. *Hordeolum may need antibiotics

What does a Peak expiratory flow meter monitor?

How fast air comes out of the lungs when forcefully exhaling

PCSK9 inhibitors MOA

Human monoclonal antibodies that bind to PCSK9 and decrease degradation of the LDL receptors in liver.

Non-pharmacological therapy in CAP

Hydration, high humidity Analgesics for pain Rest Smoking cessation, avoid secondhand smoke Patient education regarding disease, treatment, emergency treatment

What is the difference in first line treatment of COPD and asthma?

ICS is the first line therapy in asthma (Ok to use as monotherapy,) Bronchodilators are first line therapy for COPD (ok as monotherapy)

When should secondary bacterial infection be suspected with influenza?

If fever reoccurs or persist more than 4 days with cough wbc over 10,000 secondary infection should be suspected

DVT etiology

Immobilization - surgery, bed rest, travel Venous incompetence or vascular wall injury Chronic heart failure Hypercoagulable state: coagulation deficits, malignancy, estrogen use

Who should receive lipid screening and what test should be done?

In adults who are 20 years of age or older and not on lipid-lowering therapy, measurement of either a fasting or a non-fasting plasma lipid profile is effective in estimating ASCVD risk and documenting baseline LDL-C In adults who are 20 years of age or older and in whom an initial non-fasting lipid profile reveals a tri-glycerides level of 400 mg/dL or higher (‡4.5 mmol/L), a repeat lipid profile in the fasting state should be performed for assessment of fasting triglyceride levels and baseline LDL-C For adults with an LDL-C level less than 70 mg/dL (<1.8 mmol/L), measurement of direct LDL-C or modified LDL-C estimate is reasonable to improve accuracy over the Friedewald formula In adults who are 20 years of age or older and without a personal history of ASCVD, but with a family history of premature ASCVD or genetic hyperlipidemia, measurement of a fasting plasma lipid profile is reasonable as part of an initial evaluation to aid in the understanding and identification of familial lipid disorders USPSTF: Men screen at age 35, Women screen at age 45. Screen at younger age if at increased risk for CHD. Screening frequency depends upon PT risk.

Ocular Foreign Body: Management

In office -Irrigate eye with normal saline or lactated ringers for ~10 min -May dislodge foreign body with irrigation alone -Apply anesthetic eye gtts (i.e. Proparacaine HCL) for exam only -may remove non-embedded superficial FB with moistened cotton tipped applicator -May require fluorescein staining to identify corneal abrasionTetanus booster if indicated Referral If -intraocular penetration is suspected - need for slit lamp exam -Unable to remove foreign body -Presence of rust ring Home Care -Topical antibiotic for prophylaxis -Systemic analgesic as indicated

Corneal abrasion: Management

In office -Irrigate with normal saline or lactated ringers to flush out any particles or foreign body Home Care -Avoid contact lens until healed -Systemic analgesic -Prophylactic topical antibiotic to prevent infection 3-5 days or until eye pain resolved •Ofloxacin, ciprofloxacin, sulfacetamide, erythromycin, polymyxin B/trimethoprim -DO NOT USE topical steroids - can delay healing Referral/Follow up -Refer to ophthalmologist if extensive injury, signs of infection, severe ocular pain, no improvement in 24 hours -Follow up DAILY until resolved, typically 24-48 hours for simple abrasion

Oxygen therapy in COPD patients

In patients with resting hypoxemia •Typically PaO2 of 55-59 mm Hg or SaO2 88-89%; also look for evidence of cor pulmonale, peripheral edema suggesting CHF, or polycythemia (hematocrit >56%) Only drug therapy documented to improve the natural history of COPD Longer survival, reduced hospitalization, better quality of life Can prescribe •Nocturnal use only •Exercise only •Continuous ABGs preferred over oximetry to guide initial oxygen therapy Combining ventilatory support (transnasal positive-pressure ventilation) with long term O2 therapy is being studied

What factors should be considered when making recommendations for aspirin therapy for reduction of cardiovascular risk?

Individual risk of harm outweighs benefit, assess for GI and CV risks, Used in Men 45-79 to <MI risk, Women 55-79 to < Stroke risk.

Treating latent TB

Individuals with a (+) PPD or QuantiFERON-TB Gold test at increased risk for exposure or disease are generally treated Confirm that active disease is not present Consider history of past treatment for TB; contraindications for treatment Patients at risk for HIV should be tested Treatment options - 3 to 9 month treatment options •Rifamycin-based regimens, including 3 months of once-weekly isoniazid plus rifapentine, 4 months of daily rifampin, or 3 months of daily isoniazid plus rifampin are the preferred recommended regimens because of their effectiveness, safety, and high treatment completion rates.

Monitoring Asthma Control: Peak Flow Meters

Inexpensive, portable, handheld device that can be used at home Measures the amount of airflow out of large airways of the lungs during a forceful exhalation after a full inhalation Measure is called a "peak expiratory flow," or PEF ◦Measured in L/min ◦Expected results based on age, sex and size

What structure of the eye is affected in blepharitis?

Inflammation of the eye lid

Pharyngitis/Tonsillitis

Inflammation of the pharynx or tonsils caused by acute viral or bacterial infection

Blepharitis

Inflammatory disease process of eye lid Anterior - affects eyelashes and follicles Posterior - involves meibomian gland orifices

Minimizing risk of CAP

Influenza Vaccine •Deaths from influenza are usually caused by pneumonia •Influenza vaccine reduces the risk of clinical influenza Pneumococcal Vaccine •Potential to prevent or lessen severity of CAP in immunocompetent patients Reduce risk factors •Smoking cessation •Optimize treatment of chronic diseases •Educate patients at risk Good hygiene measures •Including handwashing

Respiratory viruses contributing to CAP

Influenza virus, coronaviruses

Cardiology testing based on

Information desired Cost Availability Urgency

What medications are preferred for the long-term control of asthma and are the first line agents for patients with persistent asthma?

Inhaled Corticosteroids

SMART: Single maintenance and reliever therapy. This targets patients with severe exacerbation in the prior year and in Steps 3 or 4 of treatment

Inhaled ICS-formoterol** in a single inhaler •1-2 puffs once or twice daily and 1-2 puffs prn for asthma symptoms •Maximum of 12 puffs total per day for ages ≥ 12

First line CONTROL therapy for persistent asthma

Inhaled corticosteroids

Warfarin management

Initiate with 2.5 - 5 mg QD and twice weekly INR -5 days to reach steady state so patient needs concomitant parenteral anticoagulant Review warfarin dosing adjustment guidelines in CURRENT text INR target dependent upon condition -Atrial fibrillation. INR 2.0-3.0 -Venous Thromboembolic Disease (DVT, PE). Based on location of thrombus and risk stratification. Minimum of 3 months. INR 2.0-3.0 -Mechanical heart valve. Lifelong. Aortic INR 2.0-2.5. Mitral INR 2.5-3.5 Every 4-6 weeks PT/INR if stable INR/dosing More frequent PT/INR (1-2 wks typically) with dose adjustments Even more frequent if values are extreme or condition unstable

CAD intervention: CABG

Internal mammary artery, saphenous vein or radial artery grafts Graft patency is about 85-90% at 6 months and decreases about 4% annually

corneal abrasion

Interruption of epithelial layer of cornea

Symptomatic treatment of bacterial rhinosinusitis

Intranasal corticosteroids - facial pain/nasal congestion NSAIDs/Acetaminophen - facial pain Saline nasal spray - nasal congestion, thin discharge Oral or nasal decongestants Sleeping w HOB elevated, warm facial packs, steamy shower, Neti pot AVOID antihistamines in absence of allergic component as it may worsen congestion by drying nasal mucosa

What 3 groups are clear candidates for statin therapy barring contraindications?

LDL >190 Diabetes ASCVD

What is latent TB and is it treated?

Latent infection: no active disease, not contagious. Pt may not feel symptoms.

XOFLUZA-baloxavir marboxil)

Latest FDA approved anti-viral Ages 12 and older Take a single dose orally within 48 hours of symptom onset with or without food. •Avoid co-administration with dairy products, calcium-fortified beverages, laxatives, antacids, or oral supplements (e.g., calcium, iron, magnesium, selenium, or zinc). Dosing depends on weight •40 to less than 80 kg Two 20 mg tablets taken at the same time (total single dose of 40 mg) •At least 80 kg - Two 40 mg tablets taken at the same time (total single dose of 80 mg)

Bile Acid Sequestrants

MOA •Bind bile acids in the gut, interrupt enterohepatic recirculation of bile acids and impede their reabsorption, decrease bile acid pooling in the liver, increase conversion of cholesterol to bile acids, increase the number of LDL receptors Dosing •Available as tablets or powder for suspension • Can bind absorption of other medications - administer 1 h before or 4 h after other meds •Cholestyramine, Colestipol, Colesevelam Potential side effects •May increase serum TG levels; avoid if TG >300 mg/dL •Gastrointestinal side effects may limit use

Zetia

MOA •Block the cholesterol transport protein to inhibit intestinal and biliary cholesterol absorption •increase the number of LDL receptors Dosing •Once daily •Statin/ezetimibe combinations available Potential side effects •Uncommon - diarrhea, joint pains, fatigue

Statins

MOA •Competitively inhibit HMG-CoA reductase (rate-limiting step of endogenous cholesterol production) •increase the number of LDL receptors Dosing •By desired LDL lowering and tolerance •Fluvastatin, lovastatin, pravastatin, and simvastatin have short half-lives. Administer in the evening to achieve maximum LDL-C reduction. Potential interactions •Grapefruit juice, fibrates, antifungals, macrolides, amiodarone, some CCBs •Pitavastatin is only statin minimally metabolized by CYP450 system

PCSK9 inhibitors

MOA •Human monoclonal antibodies that bind to PCSK9 and decrease degradation of the LDL receptors in liver Dosing •Alirocumab or Evolocumab SubQ injection dosed every 2-4 weeks Potential side effects •nasopharyngitis, URI, back pain, and injection site reactions •Costly

What are the most common causes of secondary HTN?

MOST COMMON: -Edema, fatigue, frequent urination (kidney disease or failure) -Snoring, hypersomnolence (obstructive sleep apnea) -Muscle cramps, weakness (hypokalemia from primary aldosteronism or secondary aldosteronism due to renovascular disease) ADDITIONAL -Medication or substance use (e.g., alcohol, NSAIDS, cocaine, amphetamines) -Prostatism (chronic kidney disease due to post-renal urinary tract obstruction) -Weight loss, palpitations, heat intolerance (hyperthyroidism) -History of coarctation repair (residual hypertension associated with coarctation) -BP lability, episodic pallor and dizziness (pheochromocytoma) -Central obesity, facial rounding, easy bruisability (Cushing's syndrome) -Absence of family history of hypertension

Pertussis Treatment:

Macrolide or Bactrim

Qualifications as VERY HIGH RISK MULTIPLE MAJOR ASCVD EVENTS OR 1 MAJOR ASCVD EVENT AND MULTIPLE HIGH-RISK CONDITIONS

Major ASCVD events •Recent acute coronary syndrome or history of MI •History of ischemic stroke •Symptomatic peripheral artery disease High risk conditions •Age ≥ 65 •Heterozygous familial hypercholesterolemia •History of prior CABG or PCI outside of major ASCVD event •Diabetes mellitus •Hypertension •Chronic Kidney disease (eGFR 15-59 ml/min) •Current smoking •Persistently elevated LCL-C (≥ 100 mg/dL) despite maximally tolerated statin therapy and ezetimibe •History of congestive heart failure

Lipid management for Primary Hypercholesterolemia Ages 20-75, LDL-C ≥ 190 mg/dL

Maximally tolerated statin therapy - - Goal: 50% reduction in LDL-C •Less than 50% reduction and/or LDL-C ≥ 100 mg/dL -Consider ezetimibe added to statin •Less than 50% reduction and/or fasting TG ≤ 300 mg/dL -Consider bile acid sequestrant to statin and ezetimibe Consider PCSK9 inhibitor •Ages 30-75 -Heterozygous familial hypercholesterolemia -LDL-C ≥ 100 mg/dL on statin and ezetimibe •Ages 40-75 -Baseline LDL-C of 220 mg/dL or higher -LDL-C 130 mg/dL or higher on max statin and ezetimibe

GOLD COPD ABCD assessment tool

May facilitate consideration of individual therapies and also help guide escalation and de-escalation therapeutic strategies for a specific patient.

Why should patients with diabetes, COPD, and asthma be monitored closely when taking a beta blocker?

May induce or exacerbate bronchospasm in asthma and COPD. Beta Blockers have adverse effects on lipids and glucose metab and can mask symptoms of hypoglycemia

Mitral valve prolapse murmur

Midsystolic click, apical

Otitis Externa: Treatment

Mild disease - topical drops (acetic acid with hydrocortisone) Moderate disease - Topical antibiotic with steroid (Cipro HC or Cortisporin) To ensure medication delivery to entire canal •Use direct visualization/curette/cotton swab to remove cerumen, desquamated skin, and drainage from EAC . •If TM is intact, EAC can be irrigated with a 1:1 dilution of 3% hydrogen peroxide and water •Wick placed in EAC for topical medication application if needed -OTC pain management (NSAIDs generally helpful) -Avoid additional moisture/water activities during healing

When should hospitalization be considered in CAP? What formulas are used to assess the need?

Minor Criteria (3 or more present) •RR ≥ 30/min •Multilobar infiltrates•Confusion/disorientation •BUN ≥ 20 mg/dL •WBC < 4000 •Platelet count < 100,000 •Hypothermia •Hypotension requiring fluid resuscitation Additional considerations: -Exacerbations of underlying dz -Other medical or psychosocial needs -Failure of outpatient therapy. Use Pneumonia severity tools such as Pneumonia Severity Index (PSI) or CURB-65

Atrial Fibrillation

Most common chronic arrhythmia, prevalence increases with age -Atria does not fully empty, resulting in poor cardiac output, stasis of blood -↑Risk for Embolism - Stroke, pulmonary Possible causes: rheumatic heart disease, sick sinus syndrome, acute MI, heart failure, pericarditis, alcohol intake S/s: May be asymptomatic or palpitations, angina, dyspnea, dizziness, syncope PE: tachycardia, irregular pulse, orthostatic hypotension, peripheral edema, JVD DX: ECG - no visible P waves; may spontaneously convert to SR within 24 hours Refer to ED or cardiology based on stability Treatment -Acute •Cardioversion (with Anticoagulation if Afib > 48 hours) •Pharmacologic cardioversion - Digoxin, beta blockers, CCBs -Chronic •Rate control - Beta blockers, Digoxin, Calcium Channel Blockers •Anticoagulant therapy to prevent stroke and embolic complications in those > 65 or with associated heart disease -Warfarin -Novel anticoagulants: Dabigatran, ivaroxaban, apixaban •Antiarrhythmics

Aortic regurgitation murmur

Most common diastolic murmur. High pitch decrescendo early diastolic heard in aortic area leaning forward

Paroxysmal supraventricular tachycardia (PSVT)

Most common paroxysmal tachycardia and often occurs in patients without structural disease •May be asymptomatic or present with palpitations, mild chest pain or SOB, rare syncope •Episodes begin and end abruptly, rapid regular rhythm •ECG shows narrow QRS, tachycardia (140-240 beats/min) •Immediate Cardiology/ED evaluation -May respond to vagal maneuvers or unilateral carotid massage -IV Adenosine, CCB, esmolol/metoprolol (BB) -Cardioversion (start at 100 J) •Prevention -AV nodal blocking agents or antiarrhythmics -Catheter ablation

Statistics of CAP in US

Most deadly infectious disease in the U.S. 8th leading cause of death 25% of cases will require hospitalization Mortality •Outpatient ~ 1% •Inpatient ~ 10-12% •1 year mortality in those > 65 years of age is over 40%

General principles with respiratory complaints

Most respiratory infections are viral. Antibiotics with •Secondary bacterial infection •Underlying respiratory condition •Prolonged symptoms Consider activity tolerance, ability to maintain hydration Would retention of respiratory secretions be detrimental? - avoid antitussives In patients with CV disease, HTN - avoid decongestants Hemoptysis - consider cancer in older patients, smokers, unresponsive to treatment after 2-3 days Asthma - diminished breath sounds without wheezing could be severe respiratory distress

What OTC medication may cause rebound congestion with extended use? What patient education should be provided?

Nasal spray decongestants Do not use more than 3 days because of rebound congestion

CAD intervention: PCI

Native arteries or bypass grafts Angioplasty - artery dilation with balloon Stent - artery dilation with stent placement •Bare metal •Drug eluting Require antithrombotic therapy Restenosis is concern

How is hypertriglyceridemia treated?

Niacin, statin, fibric acid derivatives.

1. What is the sodium goal for hypertension management?

No more than 2400mg. ** lecture states 1500. If participants cannot reach that goal, what reduction would still be beneficial? Cut by at least 1000mg

Are medications able to reverse the disease process of COPD? What is the purpose of medications in the treatment of COPD?

No, management symptoms

Other than drug resistance, what is a common reason for TB treatment failure?

Non-adherence to therapy

After appropriate medication therapy, what should you suspect in a non-resolved apparent otitis externa?

Nonadherence to medication, non-adhering to water precautions, fungal infection, ear manipulation

Diastolic dysfunction: decreased ventricular filling

Normal EF, poor ventricular compliance Often the result of hypertrophy due to hypertension disease S4 often heard

AOM: additional info

Normal exam •TMJ dysfunction, CN abnormality, Dentition, Nasopharyngeal Carcinoma OM with effusion or Serous OM •Presence of middle ear fluid without acute illness or inflammation. •Follows AOM or a result of barotraumas or allergy. •Eustachian tube dysfunction is predisposing factor. •Possible conductive hearing loss •Persistent unilateral OME - consider nasopharyngeal carcinoma Acute mastoiditis •Mastoid antrum connects middle ear to mastoid air cells. •Most AOM has some degree of mastoid inflammation/infection. •May lead to bone dissolution and require surgical evacuation Chronic otitis media •TM perforation in the setting of chronic ear infections. •Continuous or intermittent purulent aural drainage, conductive hearing loss

LIPID EVALUATION AND MANAGEMENT PLAN

Obtain baseline lipid profile screening - verify results if needed Additional labs as needed Consider secondary causes of hyperlipidemia and treat Assess lifestyle and emphasis lifestyle modification as needed Is patient in a statin benefit group? Does ASCVD risk (lifetime or 10 year) need to be considered? Clinician-patient discussion Treatment Follow-up

Long term controller meds in asthma: Immunomodulators

Omalizumab (Xolair) ◦Monoclonal antibody that binds IgE limiting degree of release of mediators of allergic response ◦Injections for moderate to severe allergic asthma

Systolic murmurs

Open - aortic/pulmonic (stenosis) Closed - mitral/tricuspid (regurgitation/prolapse)

Diastolic murmurs (always abnormal)

Open - mitral/tricuspid (stenosis) Closed - aortic pulmonic (regurgitation/prolapse)

Glaucoma: s/s

Open Angle •Painless •Slowly progressive visual loss •Peripheral loss first •Central vision affected late in disease Angle- Closure •Severe unilateral ocular pain •Blurred vision •Lacrimation •Photophobia •Halos around lights/objects •Frontal ipsilateral headache •Nausea/vomiting

Glaucoma: Management

Open-angle glaucoma •requires full work-up and management of condition by ophthalmologist Angle-closure glaucoma •Alpha adrenergic agonist, beta adrenergic blocker, prostaglandin analog, miotic eye drops or systemic carbonic anhydrase inhibitor or hyperosmotic agents to reduce IOP in office •IMMEDIATE referral to ophthalmologist for surgical treatment Patient education •Avoid OTC medications such as decongestants, motion sickness medications •Very cautious prescribing of adrenergic agents, antipsychotics, antidepressants, anticholinergics •Seek care for change in vision, eye pain or headache

You see a whitish area on your client's tongue. What do you suspect if _______ if it wipes off. You suspect__________ if it does not rub off.

Oral candidiasis (Wipes off easily leaving underlying red, raw surface) Hairy leukoplakia (won't rub off)

Points of discussion for COPD patient

PREVENTION •Exacerbations affect QOL and prognosis of patients •Medication compliance •Avoiding irritants/infectious exposure •Prompt presentation for worsening symptoms FOLLOW UP •Frequency depends on severity of disease, frequency of exacerbations, reliability of patient/ social support system SPIROMETRY/SYMPTOMS •May take several weeks after exacerbation to normalize to baseline ADVANCED DIRECTIVES •After resolution of exacerbation, opportunity to discuss end of life wishes

Acute Peripheral Arterial Occlusion

Pain, paresthesia, paralysis, pallor, pulseless Avoid elevating extremity IV Heparin therapy immediately Doppler ultrasound or angiography direct revascularization

Individuals with elevated triglycerides are at risk for what disease process?

Pancreatitis

GI causes of CP

Pancreatitis •Hx ETOH, hyperlipidemia or incretin mimetics •Sudden severe diffuse pain in epigastric or LUQ with radiation to back, N/V •↑ amylase & lipase Cholecystitis •5 F's -fair, fat, forty, fertile, and female •Fatty food intolerance •+ RUQ pain, (+) Murphy's sign •Pain may radiate to back or right shoulder GERD •Burning, substernal pain related to consuming large meal, lying down or bending over •Pain is usually relieved by ingestion of antacid Peptic Ulcer •Gnawing epigastric pain •Relieved by antacids •Variability with meals Esophageal spasm •Substernal, radiation to neck, shoulder, arm •Relieved by NTG

Assessing BP

Patient prep •Relaxed with empty bladder, sitting in a chair, feet on floor, back supported for >5 min. •At least 30 min after caffeine, exercise, or smoking. •No talking! •Do not take BP with patient sitting or lying on an exam table Proper technique •Do not put BP cuff over clothing •Support the patient's arm (e.g., resting on a desk). •Measured with a well-calibrated instrument •Bladder width of cuff should encircle at least 80% of the arm circumference •Position the middle of the cuff on the patient's upper arm at the level of the right atrium.

How does the recommendation for a flu vaccine in adults 65 and over differ from younger adults?

Patients 65 years and older should receive a high dose trivalent inactivated influenza vaccine containing four times more hemagglutinin than standard dose. It enchances the immune response to vaccine

PCSK9 inhibitors approved for use in what patients?

Patients that have already had a cardiac event (insurance won't cover until this) L Costly $$$ Those with genetic high cholesterol, serious heart disease, or those who cannot take statins and need their LDL lowered.

What individuals are at greatest risk for complication of the flu?

Patients with asthma, residents of long-term care facilities, age >65, morbid obesity, underlying medical conditions. Infection during pregnancy increases risk for hospitalization and complications.

When should antibiotics be considered in COPD treatment?

Patients with purulent and an increase in sputum production

Additional diagnostic testing in asthma

Peak Expiratory Flow •≥ 80% of predicted or personal best is good Pulse oximetry Chest x-ray •Usually normal or hyperinflationSkin testing - allergy CBC - exclude anemia as cause for dyspnea •slight ↑ WBCs during acute attack with eosinophilia r/t to allergic attack ABGs •Can be normal during mild exacerbation, but respiratory alkalosis is common •Mild arterial hypoxia/ hypocapnia indicate fatigue of accessory muscles

What medications are appropriate in the treatment of GABHS?

Penicillin V 500mg BID x 10day Cefuroxime 250mg BID x 5-10 days Erythromycin 500mg BID x 10 days Azithromycin 500mg qd x 3 days

If your client has a Streptococcal infection etiology to their sore throat and you suspect that medication compliance may be a problem, what would be the best treatment option?

Penicillin VK IM injection

What groups should receive high intensity statin therapy?

Per lecture: High intensity statin in ages 40-75: o Clinical ASCVD o Severe primary hypercholesterolemia o High 10-year ASCVD risk for primary prevention o With DM and multiple risk factors or age 50-75

LDL reduction

Percentage of LDL-C reduction from baseline is more reliable indicator of risk reduction than mg Primary Prevention •Prevent ASCVD events •Greater risk reduction at higher baseline LDL-C levels Secondary Prevention •Reduction in CV events/deaths and all-cause mortality

Calcium channel blockers

Peripheral vasodilatation ↓ afterload Dilate coronaries, ↓ myocardial contractility, depress AV conduction Non-dihydropyridine CCBs can slow down HR Dihydropyridine CCBs (end in -pine) do not slow down HR

Vertigo: Peripheral vs Central cause

Peripheral vestibular disease •Sudden onset - morning, turning over in bed •Unable to walk/stand •Accompanied by N/V •Tinnitus and hearing loss may be associated •Fixed nystagmus, which always beats in the same direction Central disease •Develops gradually and becomes progressively more severe •Neurologic symptoms: Double-vision, facial numbness, hemiparesis •Nystagmus is inconsistent REFER any patient who exhibits NEUROLOGIC deficits/symptoms, recurrent vertigo, or has unclear etiology

Pharyngitis/tonsillitis assessment: Mono

Posterior cervical lymphadenopathy Shaggy white purple exudate

What are the top three most likely causes of a persistent cough in adults with normal chest x-rays?

Postnasal drip, asthma, GERD

Causes of CP: electrolyte abnormalities

Potassium↓ - broadened T waves, prominent U waves, depressed ST segments, PVCs Potassium↑ - bradycardia, peaked T waves, widened QRS, BBB, AV block, V fib Calcium↓ - skeletal muscle spasm, prolonged QT interval predisposes to ventricular arrhythmias Calcium ↑ - ventricular ectopy, idioventricular rhythm

How do flu vaccines differ from year to year? Why do they differ?

Predicted strain year to year

If individuals with CAP are also positive for influenza, when should they receive antiviral treatment?

Prescribe antiviral treatment if positive for flu, independent of duration of illness before diagnosis

viral rhinosinusitis- the common cold

Presentation •Nasal congestion, watery rhinorrhea, sneezing, general malaise, throat discomfort, headache •Erythematous, edematous nasal mucosa with watery discharge Symptomatic relief •Zinc 75 mg per day •Saline nasal irrigation •Oral decongestants •Nasal spray decongestants (no more than 3 days) •RESIST the urge to treat viral RS with antibiotics!

A 17-year-old male reports a persistent non-productive cough, chest tightness, and wheezing which began a few days after he started working at a horse farm 6 weeks ago. His symptoms are worse during the day. He denies rhinitis, postnasal drip, or history of seasonal allergies. He takes no prescription or over-the-counter medications. On physical examination, the patient speaks in complete, uninterrupted sentences with no work of breathing. His temperature is 98.6 F, blood pressure is 120/70 mm Hg, heart rate is 88 beats per minute, respiratory rate is 18 breaths per minute, and oxygen saturation is 96% on ambient air. Physical exam reveals nasal and oropharyngeal mucosa without erythema or exudates, and no sinus tenderness; bilateral diffuse expiratory wheezes; intermittent dry cough; and S1, S2 without murmur or rubs. The remainder of the exam is unremarkable. Chest x-ray and CBC, including differential are normal. What 2 differential diagnoses would you consider? What diagnostic test would be helpful in identifying this patient's diagnosis?

Primary differential diagnoses in this case would be asthma and allergic reaction. Spirometry with pre- and postbronchodilator testing is the standard diagnostic approach for suspected asthma, as it assesses reversible airflow limitation. If pulmonary function testing was normal, dermal patch testing could be considered as a second step, as it may identify some irritants that trigger allergies. The presence of wheezes indicates it is likely more severe than just seasonal or standard environmental allergies and testing would be indicated to prevent further lower respiratory symptoms.

Mitral Valve Prolapse

Prolapse of mitral leaflets into the left atrium -May or may not have regurgitation Echocardiography confirms diagnosis Physical Exam -Mid systolic click -pansystolic or late systolic murmur suggests MR -Sound decreases when squatting May be asymptomatic - no treatment SX often related to hyperadrenergic state -nonspecific CP, anxiety, fatigue, palpitations, lightheadedness, dyspnea -Sometimes associated with dysautonomia Initial evaluation by cardiology If MR present, periodic echo to assess LV size - Can progress to enlargement of LA, LV Treatment of MVP -Beta blockers for palpitations, helps with anxiety -Avoid diuretics - less volume= more symptoms -Adequate water intake, limit caffeine -Severe - MV repair **Does NOT require bacterial endocarditis prophylaxis

How to make a confirmatory diagnosis of asthma

Pulmonary function tests (PFTs) are essential for dx. - Increase of >12% and 200ml in FEV1 after bronchodilator. -Increase of >15% and 200ml in FVC after bronchodilator

Diagnostic testing for seasonal influenza

Rapid assay detection from nasal or throat swabs •Approx 60-80% sensitive May see leukopenia and proteinuria Diagnosis is generally made based on clinical presentation •Fever and cough during flu season in the absence of other diagnostic confirmation

Epiglottitis

Rapid development of inflammation and edema of supraglottic structures and epiglottis leading to narrowed airway and respiratory compromise

rhinitis medicamentosa

Rebound congestion due to overuse or extended use of nasal decongestants May occur after 3 days of continuous use Treatment •Cessation of use •Intranasal corticosteroid spray •Intranasal anticholinergic nasal spray •Short tapering course of oral prednisone

Aphthous ulcers "canker sores"

Recurring but not contagious or seasonal •Usual location - Buccal mucosa, ventral tongue

Anti-Inflammatory: Inhaled corticosteroids in asthma

Reduce acute and chronic inflammation resulting in improved airflow, ↓ airway hyper-responsiveness, fewer asthma sx/exacerbations

Goal of Asthma Treatment

Reduce current impairment ◦↓ symptoms, maintain lung function, normal activity Reduce future risk ◦ER visits, exacerbations, loss of lung function

CAP Pathology

Reduction or loss of pulmonary defense mechanisms Pathogen overwhelms the immune response Pathogen is unidentified in many cases

What is the most appropriate action by the NP for individuals with suspected keratitis or iritis?

Refer immediately to ophthalmology

Cerumen removal

Removal Options •Cerumenolytic agents -Mineral oil, hydrogen or carbamide peroxide, liquid docusate -May use as maintenance with frequent recurrence •Gentle Irrigation with large syringe and warm water •Manual removal by clinician Potential complications •Allergic reaction, otitis externa, pain/earache, tinnitus, transient hearing loss, dizziness/vertigo, water retention behind incompletely removed cerumen

renin-angiotensin-aldosterone system

Renin •sympathetic nerve activation •renal artery hypotension (systemic hypotension or renal artery stenosis) •decreased sodium delivery to the distal tubules of the kidney ↓ Angiotensin I ↓ Angiotensin Converting Enzyme (ACE) ↓ Angiotensin II •Constricts resistance vessels (via angiotensin II receptors) increasing systemic vascular resistance and arterial pressure •Stimulates the release of vasopressin which increases fluid retention by the kidneys •Stimulates thirst centers within the brain •Facilitates norepinephrine release and inhibits norepinephrine re-uptake, thereby enhancing sympathetic adrenergic function •Stimulates cardiac and vascular hypertrophy ↓ Aldosterone •acts on the kidneys to increase sodium and fluid retention

In patients with acute coronary syndrome, what is the most important treatment?

Reperfusion- heart cath

Tx of seasonal influenza

Rest Fluids Analgesics, possible cough suppressant Neuraminidase (antiviral) inhibitors •Maximum benefit with earliest initiation •Most effective if started within 48 hrs of symptom onset Zanamivir 2 inhalations BID x 5 days -Contraindicated in patients with asthma Oseltamivir 75 mg BID x 5 days -Both have potential for transient neuropsychiatric events

Acute bronchitis: recommended treatment/management:

Rest, hydration, humidification, smoking cessation. Antibiotics not use in viral EXCEPT secondary bacterial infections or Adults w/ COPD (Amoxicillin, Bactrim, clarithromycin, azithromycin.) Consider antivirals if influenza. Avoid antihistamines- dry out secretions. Decongestants if sinus component. Antipyretic for fever. Cough suppressants at night if cough disturbs sleep. Inhaled beta agonist for cough with bronchospasm.

What are possible dangerous GABH Strep complications?

Rheumatic fever Glomerulonephritis

Describe the main concepts of the DASH diet? (Dietary Approaches to Stop Hypertension)

Rich in fruits, veggies, whole grains, low fat dairy, reduced saturated & total fat

In COPD patients: Potential for Right heart failure (Cor Pulmonale). Admit/refer to pulmonologist

Right Heart Failure Symptoms •Dyspnea at rest •Fatigue, syncope, angina during exertion •Impaired cognition •Peripheral edema, weight gain •Cyanosis and JVD •Holosystolic murmur and S3 •Hepatomegaly •Erthrocytosis •Renal function abnormalities

Concerns with resistant HTN

Risk of MI, stroke, ESRD, and death in adults with resistant HTN and CHD may be 2- to 6-fold higher than in hypertensive adults without resistant HTN Risk factors: older age, obesity, CKD, black race, DM

Typical pneumonia

S/S •Appear very ill •Sudden onset •High fever, shaking chills •Pleuritic chest pain, SOB •Productive cough •Sputum changes from watery to blood tinged or rust colored •Tachypnea is prevalent in elderly •Malaise More likely to have •Adventitious breath sounds •Dullness on percussion •Abnormal transmitted voice sounds CXR •Typically consolidated lobar pneumonia WBCs •Typically >15,000 •Milder elevation in elderly or immunocompromised

Atypical pneumonia

S/S •Mildly to moderately ill •Gradual and insidious onset •Fever - may be low grade •Headache •Pharyngitis •Malaise, myalgias •Diarrhea •Dry, hacking cough Less remarkable physical exam •May have crackles or rhonchi CXR •Usually appears as interstitial patchy infiltrates; consolidation is unusual WBCs •Typically < 15,000

How is ASCVD risk calculated in patients with HTN?

Same info is put into the calculator (age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status) and a HTN complication risk is determined. ASCVD risk- http://tools.acc.org/ASCVD-Risk-Estimator/

What is Vertigo and what type of evaluation assists in determining the underlying etiology?

Sensation of motion when there is no motion or exaggerated sense of motion in response to motion. History- onset, duration, associated symptoms, medications, co-morbidities Ears- anatomy and function Vision screening Nystagmus- Dix-Hallpike Cranial nerves Cardiovascular- rhythm, bruits

Vertigo

Sensation of motion when there is no motion or exaggerated sense of motion in response to movement •Central -Vascular, neoplastic, CNS disease -Vascular insufficiency, transient ischemic attack, stroke, migraine HA, neoplasm, MS •Peripheral (external to brain stem/cerebellum) -Disruption of the inner ear or vestibular apparatus -Benign Paroxysmal Positional Vertigo -Vestibular Neuronitis -Meniere's disease •Systemic Causes -Psychogenic, Cardiovascular, Metabolic

Once diagnosed, how is the patient's COPD class or stage determined?

Severity is based on post-bronchodilator FEV1: I: MILD FEV1 >80% PREDICTED II: Moderate FEV1 50 to <80% predicted III: Severe FEV1 30 to <50% predicted IV: Very severe FEV1 <30% predicted

How do short and long-acting beta agonists differ?

Short acting beta agonists have bronchodilator effects that last four to six hours. Long-acting beta agonists have bronchodilator effects that last 12 to 24 hours.

What is SMART therapy?

Smart therapy is the use of a combination inhaler containing budesonide and etw4formoterol as both maintenance and quick relief therapy (ICS/LABA)

What is the single most important intervention in smokers with COPD?

Smoking cessation

Pharyngitis/tonsillitis assessment: GABHS

Soft palate petechiae Scarlet fever rash

What role do anticholinergics play in COPD treatment?

Some clinicians prefer SAMA as first line therapy due to longer duration and absence of sympathomimetic side effects. Others prefer SABA due to faster onset of action. Per our power point- Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator

How would a coronary artery calcium score be beneficial in making treatment decisions?

Specialized x ray that helps to make decision on whether or not to start medication by measuring plaque building risk. 0= no calcium and low risk, 100-300= moderate risk of plaque deposits, >300= very high to severe disease and heart attack risk. Basically: helps determine if someone who is on the borderline needs treatment or not based on their risk.

What diagnostic testing is required to confirm the diagnosis of COPD? What result signifies airflow limitation?

Spirometry, Post-bronchodilator FEV1/FVC ratio < 70% (0.70)

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

Statin Benefit groups Statin Intensity No target LDL level

2018 AHA/ACC Multi-SocietyGuideline on the Management of Blood Cholesterol

Statin benefit groups Statin intensity LDL-C Thresholds Additional lab testing "Risk enhancing" factors Non-statin therapies as treatment adjuncts

What medication class should be used for quick relief of symptoms during acute asthmatic attacks in step 1 and 2 of asthma treatment?

Step 1--Short Acting Beta Agonist Step 2-- Low Dose Inhaled Corticosteroids

First line treatment for each stage of asthma

Step 1: SABA PRN Step 2: Low dose ICS Step 3: Low-dose ICS + LABA or medium dose ICS Step 4: Medium- dose ICS + LABA Step 5: High dose ICS + LABA Step 6: High dose ICS + LABA + Oral Corticosteroid

Explain asthma step-up/step-down treatment:

Step up if needed, check adherence environmental control, and comorbid conditions assess control step down if possible when asthma is controlled for at least 3 months

What are the classic symptoms of angina? What populations more commonly have atypical presentations?

Substernal pain with radiation to shoulders, neck, jaw, arms, epigastrium, and possibly upper back. Described as pressure , tightness, heaviness. Lasts for minutes. Precipitated by exercise or emotional stress. Relieved by rest or NTG. Elderly, women, and diabetics more likely to have atypical presentations

What are the symptoms of abdominal aortic aneurysm dissection? Who is most at risk and should be screened?

Sudden onset of knife-like/ tearing pain in chest or upper abdomen Possible radiation to the back History of hypertension and/or smoking Male smokers are at higher risk Screen >65 history of sever smoking

ACS symptoms

Sudden onset substernal pain/heaviness with possible radiation to left shoulder/arm, neck, jaw, between shoulder blades, dyspnea, diaphoresis, N/V, anxiety. Pain unrelieved by NTG or rest

Which cardiac diagnostic tests best provide information regarding oxygen supply to the myocardium? Which one is diagnostic, rather than suggestive, of coronary artery disease?

Suggestive- Nuclear myocardial perfusion imaging Diagnostic- Cardiac catherization (coronary angiography)

When would cerumen excess/impaction removal with irrigation be contraindicated and why?

Suspected TM perforation, tympanostomy tube, coexisting ear problems (ear infection) Potential complications: Allergic reaction, otitis externa, pain/earache, tinnitus, transient hearing loss, dizziness/vertigo, water retention behind incompletely removed cerumen

Otitis Externa: Follow up and referral

Sx improvement in 36- 48 hrs with full symptom resolution in about six days Return to clinic in 1 week or sooner Unresponsive to treatment -Ask about medication adherence, water precautions, ear manipulation. -Culture ear canal and/or refer to ENT REFER IMMEDIATELY FOR -Advanced infection, suspect malignant otitis externa (ulcerations, facial nerve palsy, mastoid tenderness, cellulitis, fever, chills, malaise

What is viral rhinosinusitis and its recommended treatment? The common cold

Symptomatic relief Zinc 75mg/ day Saline nasal irrigation Oral decongestants Nasal spray decongestants (no more than 3 days)

Otitis Externa: Presentation

Symptoms •Ear pain, itching, drainage Physical Exam •Otalgia - (+) Tug Test •Edema and/or exudate in EAC •EAC may be narrowed by edema, debris, exudate •TM may not be visible, but TM "skin"may be erythematous but will be mobile

chronic venous insufficiency s/s and PE findings

Symptoms and PE findings •Pain varies from minimal discomfort to marked pain •May be described as aching •LE edema worsens with standing, improves with elevation •Mild pruritus of LE •Hyperpigmentation (brown/reddish or brawny) and thickening of skin on LE •Stasis ulcers - may weep and crust; usually medial

Acute Rhinosinusitis

Symptoms less than 4 weeks duration

pulmonary tuberculosis (TB)

Systemic disease caused by Mycobacterium tuberculosis, of which pulmonary disease is the most common presentation

Mitral regurgitation murmur

Systolic: Apex, L lateral decubitus position, holosystolic blowing, may be loud, radiates to left axilla/back

physiologic murmur

Systolic: LSB 3rd-4th ICS while supine, early to midsystolic, disappears when sitting up or holding breath

How is TB screening performed

TB screening is performed by a tuberculin skin test (Mantoux PPD) 0.1 ML Purified Protein Derivative containing 5 TB units is injected intradermally on the volar surface of the forearm with 27G needle. Transverse width in mm of induration at test site is measured in 48-72 hours criteria for positive reaction are based on prior likelihood of infection. Less sensitive with previous (BCG vaccine) Does not distinguish between active and latent infection (Quantiferon TB gold test) Less subject to reader error Single Patient visit Less like to be positive after BCG vaccine

Bloody sputum, weight loss, change in cough --Consider

TB, lung cancer

In what condition are bile acid sequestrants contraindicated?

TG >300mg/dL

Physical exam findings that may be present in asthma

Tachypnea Tachycardia Prolonged expiration Audible wheezing Use of accessory respiratory muscles Resonance Cyanosis Decreased responsiveness

BP follow up

Team-based care •Ophthalmologist and Specialist if comorbidity Health information technology •ABPM, HBPM, Telehealth, patient portal Nonadherence •Monthly follow up until BP control is achieved •Assess adherence, practice shared decision making Patient Education and Health promotion

Potassium and blood pressure

The BP-lowering effect of increased potassium intake in individuals consuming a high-sodium diet has been up to twice as much as those who are not. A reduction in the sodium/potassium index may be more important than the corresponding changes in either electrolyte alone Foods high in potassium: Bananas, Orange Juice, Oranges, Apricots, Grapefruits, Dates, Watermelon, Cantaloupe, Tomatoes, Raisins, Prunes, Peanuts, Mushrooms, Avocado, Asparagus, Spinach, Squash, Sweet potato, Beans, Broccoli, Carrots

Which classes of drugs are first line for the treatment of HTN in individuals of the black race?

Thiazide-type diuretic or CCB

Ocular Trauma

Thorough but safe clinical assessment, supplemented when necessary by imaging, is crucial to effective management. Consider ocular damage and need for early assessment by an ophthalmologist in any patient with facial injury.

What is the Gold standard for determining presence of bacterial infection of the throat?

Throat culture

venous thrombosis

Thrombosis: RBCs, platelets, and fibrin attached to part of inflamed vessel wall

Murmurs- What to assess

Timing/Duration •Systolic - More common, can be benign•Between S1/S2 •Diastolic - Always abnormal •Between S2/S1 •Holo/Pan- throughout •Mid •Decrescendo- Starts off loud at the beginning then tapers off •Crescendo- Starts soft at the beginning and gets louder Quality •Harsh, blowing, musical, rumbling, vibratory, soft Location - (aortic, pulmonic, tricuspid, mitral areas) Radiation - murmur heard in another place (neck, axilla). Sound usually radiates in the direction of blood flow

Expanded abx coverage in CAP:

To better treat beta-lactamase-producing H. influenzae, Moraxella catarrhalis, and methicillin-susceptible S. aureus for older patients, smokers, and those with comorbidities and/or recent antibiotic use.

CHOLESTEROL LEVELS

Total cholesterol •Optimal for prevention of ASCVD - 150 mg/dL LDL-C •< 100 mg/dL without comorbidities •< 70 mg/dL with comorbidities HDL-C •Higher is better •Prefer > 50 mg/dL Triglycerides •Normal: < 150 mg/dL •High: 200-499 •Very High: > 500 • > 1000 - risk for pancreatitis

Tuberculosis transmission

Transmission: Inhalation of aerosolized droplets from an infected person -Infection occurs if inoculum escapes alveolar macrophage microbicidal activity -Immunocompetent individuals can contain (but not eradicate) TB to prevent multiplication and spread

Keratitis: Etiology

Trauma, history of herpes simplex, bacterial infections, contact lens wear

During acute asthma attack

Treat without delay! Assess severity of respiratory distress Ask questions as you are administering meds.

HEENT HPI focus

Trigger--> Exposure--> Onset Symptoms •Pain •Discharge Change in function Progression or Change Associated manifestations Systemic symptoms Current treatment

What is the most sensitive lab marker of cardiac myocyte damage?

Troponin

Which patients with venous thromboembolic disease are appropriate candidates for outpatient treatment?

Uncomplicated DVT LMWH + warfarin 5mg x 5 days and until INR is 2-3

Seasonal influenza: Prognosis and Prevention

Uncomplicated illness lasts ~ 1-7 days Secondary bacterial infection is primary complication •Sinusitis, pneumonia, OM, bronchitis Primary prevention •Annual influenza vaccine for 6 months and older Prevention after exposure •Oseltamivir 75 mg or Zanamivir 2 inhalations daily x 7days •Begin within 48 hours of exposure

OSA etiology

Upper airway obstruction occurs when loss of normal pharyngeal muscle tone allows the pharynx to collapse passively during inspiration

Continued warnings about LABA as monotherapy for asthma

Use of LABA as monotherapy (without ICS) for asthma is associated with an increased risk of asthma-related death

CAP Clinical Presentation - Physical Exam

Varies due to pathogen , age, and underlying health of patient Typical •More likely to affect those over age 65 •Rapid onset •Pathogens: S.pneumonia, H influenzae, & Klebsiella pneumonia •Affects all or part of a lung lobe (lobar pneumonia) •More likely to have striking physical findings Atypical •Most commonly seen in young adults •More insidious onset •Pathogens: M pneumoniae, Influenza viruses, C pneumoniae, Legionella •Chest x-ray shows interstitial patchy infiltrates •Physical exam may be less remarkable

Venous Dermatitis vs Cellulitis

Venous Dermatitis -Itching and crusting of skin -Skin isn't acutely painful or hot and is more ruddy than red -Patient is afebrile Cellulitis -Rarely bilateral or chronic -Skin is hot, acutely painful, edematous, and indurated. May have peau d'orange appearance -Redness spreads with irregular, defined borders, and slight elevation

Pharmacological therapy for Viral Conjunctivitis

Viral (non-herpetic) •No specific antiviral agent for the treatment of viral conjunctivitis. •Symptomatic relief •Topical OTC antihistamine/decongestants - Naphcon-A, Ocuhist, generics •OTC Eye lubricant drops 1 to 2 drops every 1 to 6 hours as needed •Eye irritation and discharge may get worse for 3-5 days before getting better. •Symptoms can persist for two to three weeks Viral (herpetic) - refer immediately

What are the differences in physical exam findings for viral, bacterial and allergic conjunctivitis?

Viral: Profuse tearing Generalized eye hyperemia Preauricular lymphadenopathy Occasional association with sore throat and fever Minimal exudate Minimal pruritus Bacterial: Often starts in one eye and spreads to both Occasionally associated with sore throat or fever Profuse exudate Conjunctival chemosis/edema, Generalized eye hyperemia Moderate eyelid edema Moderate tearing Preauricular adenopathy less likely Pruritus - mild if present Allergic: Severe itchy eyes Moderate tearing Stringy discharge Usually, bilateral Generalized eye hyperemia Chemosis/conjunctival/eyelid edema Cobblestone appearance Rhinitis, sneezing, seasonal or dander allergies Minimal exudates Not associated with sore throat or fever

Vision threatening s/s Immediate referral required for

Visual abnormalities -Blurred vision that does not clear with blinking -Acute loss or decreased vision -Halos around sources of lights -Flashing lights/arcs of light -Sudden floating spots or sensation of cobwebs across field of vision -Photophobia Pain -Periocular headache -Ocular pain Abnormal Physical Exam -Nystagmus -Ciliary flush -Corneal damage -Abnormal pupils -Increased intraocular pressure -Shallow anterior chamber -Proptosis -Green-yellow discharge, eye erythema, chemosis, lid edema

When a patient presents to the primary care office with a complaint involving the eye, what is the most important evaluation tool to help determine the urgency of the complaint?

Visual acuity

CAP physical assessment

Vital signs •Temp, HR, respiratory rate, BP, pulse oximetry Level of consciousness Respiratory •Breath sounds -Absent or diminished -Adventitious sounds - cough to clear and relisten •Work of breathing •Transmitted voice sounds •Percussion notes Hydration status

OSA treatment

Weight loss and strict avoidance of alcohol and hypnotic medication are the first steps in management. Weight loss may be curative, but most patients are unable to lose the 10-20% of body weight required. CPAP at night is required for most patients UP3 is helpful in approximately 50% of selected patients Nasal septoplasty is performed is gross anatomic nasal septal deformity is present Tracheostomy relieves upper airway obstruction and its physiological consequences and represents definitive treatment but has numerous adverse effects.

Hearing loss: testing

Whisper Test •Conductive: Decreased low tones, vowels •Sensorineural: Decreased high freqency Weber test •Conductive: Lateralization to affected ear •Sensorineural: Lateralization to non-affected ear Rinne test •Conductive: BC = to or > AC •Sensorineural: AC > BC

What is white coat hypertension and masked hypertension? What is the plan of care if either of these conditions is suspected?

White coat: elevated office BP but normal readings outside the office with either ABPM or HBPM. -Higher with increasing age, female, nonsmoking -confirm with ABPM Masked hypertension: office readings suggest normal BP but out-of-office (APBM/HBPM) readings are consistently above normal. -prevalence varies from 10-26% -risk of CVD and all-cause mortality is similar to those with sustained HTN and about twice as high as normotension individuals -confirmation of the diagnosis by ABPM might be reasonable before intensification of antihypertensive drug treatment.

In what time frame should antiviral therapy for influenza be started to obtain maximum benefit? What medications are available?

Within 48 hours Zanamivir, Oseltamivir, Xofluza

Ocular trauma: Diagnostics

Within the FNP scope, but must have equipment for adequate assessment -Fluorescein stain -Eye irrigation equipment -Ophthalmic local anesthetic -Slit lamp

Should a COPD patient receiving a systemic corticosteroid on a regular basis be put on any concurrent treatment? If so, what?

Yes, do not give systemic corticosteroid alone. Should be given with a LABA.

Is there a need for a "rescue inhaler" in COPD patients? Why or why not?

Yes, it improves the comfort of the patient and helps decrease air hunger. It does not reverse effects of COPD.

You note an elevated fasting blood glucose on a non-diabetic patient on statin therapy for 6 months. Could this be a result of the medication?

Yes.

Stage 1 HTN, clinical CVD or estimated risk ≥ 10% Initiation with

a single antihypertensive drug

What factors enhance the risk of ASCVD?

a. Family history of premature ASCVD i. (males, age <55 y; females, age <65 y) b. Primary hypercholesterolemia i. LDL-C 160-189 mg/dL ii. non-HDL-C 190-219 mg/dL c. Metabolic syndrome (at least 3 factors present) i. increased waist circumference ii. elevated triglycerides [>150 mg/dL, nonfasting] iii. elevated blood pressure iv. elevated glucose v. low HDL-C [<40 in men; <50 mg/dL in women] d. Chronic kidney disease i. eGFR 15-59 mL/min with or without albuminuria; not treated with dialysis or kidney transplantation e. Chronic inflammatory conditions i. Psoriasis, RA, lupus, or HIV/AIDS f. History of i. premature menopause (before age 40 y) ii. pregnancy-associated conditions that increase ASCVD risk, such as preeclampsia g. High-risk race/ethnicity h. Lipids/biomarkers associated with increased ASCVD risk i. Persistently elevated primary hypertriglyceridemia 1. ≥175 mg/dL, nonfasting ii. Elevated hsCRP ≥2.0 mg/L iii. Elevated Lp(a) ≥125 nmol/L iv. Elevated apoB ≥130 mg/dL v. Ankle Brachial Index < 0.9

A 26-year-old woman reports that for several years, she has had random episodes of palpitations and shortness of breath that resolve spontaneously. She denies chest pain, arm pain, and syncope. Her past medical and family histories are negative for coronary artery disease, stroke, or lung disease. During the cardiac exam, the nurse practitioner notices a grade 2/6 murmur that is accompanied by a mid-systolic click, which is heard best heard at the apical area. The apical pulse is 78 beats/min, blood pressure is 120/60 mmHg, and temperature is 98.6°F. The cardiac exam is highly suggestive of which of the following conditions, and what diagnostic test would you perform to confirm? a. Mitral valve prolapse b. Aortic stenosis c. Atrial septal defect d. Coronary artery disease

a. Mitral valve prolapse Echocardiogram would be performed

Define normotension, elevated BP, and stages of HTN in mm/Hg.

a. Normotension: <120/<80 b. Elevated: 120-129/<80 c. Stage I HTN: 130-139 OR 80-89 d. Stage II HTN >140 OR >90 Blood pressure based on an average of ≥ 2 careful readings obtained on ≥ 2 occasions When systolic and diastolic pressures fall into different categories, the higher category should be used to classify BP stage

Deep Vein (DVT):

acute blood clot formation in the deep lower extremity or pelvic veins with ambiguous presenting signs or symptoms

Mononucleosis

acute illness caused by Epstein-Barr virus (EBV) with fever, fatigue, pharyngitis and adenopathy

superficial venous thrombosis

acute inflammation and clot formation with associated redness and tenderness along superficial veins

What non-pharmacologic treatment measures are important in COPD patients?

adequate hydration (for mobilization of secretions), effective cough training methods, use of handheld flutter device

What role does alpha-1 antitrypsin play in COPD? Genetic role (young diagnosis of COPD)

alpha-1 antitrypsin is available for replacement therapy in emphysema due to congenital deficiency of alpha-1- antiprotease. This is administered IV in a dose of 60mg/kg body weight once weekly

Outpatient CAP treatment per 2019 IDSA/ATS CAP Guidelines For previously healthy patient with NO risk factors for antibiotic resistant pathogens

amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence) doxycycline 100 mg BID (conditional recommendation, low quality of evidence) macrolide only in areas with pneumococcal resistance to macrolides < 25% -azithromycin 500 mg 1st day, then 250 mg daily; or clarithromycin 500 mg BID or clarithromycin ER 1,000 mg daily) (conditional recommendation, moderate quality of evidence)

If concomitant infection of GABHS and Mono, do not treat the GABHS with __________. May elicit rash

ampicillin or amoxicillin

Epistaxis : Hemorrhage is most common in

anterior septum (Kiesselbach plexus)

When would apoB and Lp(a) labs be drawn?

apoB: Consider if triglycerides > 200 mg/dl Lp(a): consider if family history of premature ASCVD or personal history of ASCVD not explained by major risk factors. In women, the risk is considered enhanced only in the presence of hypercholesterolemia.

superficial thrombophlebitis risk factors

aseptic procedures

Paroxysmal dry, hacking cough made worse by cold or exercise or nocturnally-- Consider

asthma

FeNO levels greater than 50 are consistent with elevated T2 inflammation and support a diagnosis of

asthma. •Allergic rhinitis and atopy are associated with increased FeNO levels. Taking these factors into consideration is critical for accurately interpreting FeNO test results.

Asthma symptoms worse _________

at night, with exercise, exposure to cold temperatures, smoke, or allergens

Hyphema

blood in the anterior chamber of the eye

Modified British Medical Research Council (mMRC) Questionnaire for COPD measures

breathlessness and relates well to other measures of health status and predicts future mortality risk

Pts w/ asthma can have normal PFTs. May need

bronchoprovocative test

Short acting beta2 agonist is drug of choice in acute exacerbation at all levels of asthma due to rapid relaxation of airway smooth muscle. Used in step 1 treatment for intermittent asthma ◦Scheduled daily use not recommended. Potential for excess _______

cardiac stimulation

No individual symptom or constellation of symptoms is adequate for diagnosis of CAP without

chest imaging

An 81-year-old man with a 75-pack-year history of cigarette smoking reports, during a routine follow-up visit, that he quit smoking 3 months ago. His last spirometry (2 months ago) documented an FEV1 of 44% of predicted and an FEV1/FVC ratio of 69%. The patient has not had any hospitalizations or emergency department visits in the past year. He feels his breathing-related symptoms have been well controlled on his current inhaler regimen: albuterol as needed, daily tiotropium, and twice-daily fluticasone-salmeterol. Vital signs: Temp 98.6F, HR 89, RR 19/ minute, BP 126/72, oxygen saturation of 88% while he is breathing ambient air. His physical examination is significant only for diminished air movement bilaterally. Arterial blood gas testing reveals a pH of 7.36 (reference range, 7.38-7.44), carbon dioxide of 48 mm Hg (35-45), and oxygen of 54 mm Hg (80-100). Which one of the following is the best course of treatment? a. Add ipratropium to the inhaler regimen b. Initiate treatment with low-dose prednisone c. Begin daily azithromycin d. Begin long-term supplemental oxygen therapy e. Begin theophylline

d. Begin long-term supplemental oxygen therapy A patient with chronic obstructive pulmonary disease and hypoxemia who is on an adequate pharmacologic regimen should begin long-term supplemental oxygen therapy. According to Global Initiative for Chronic Obstructive Lung Disease criteria, patients with chronic obstructive pulmonary disease (COPD), regardless of severity, should be treated with long-term supplemental oxygen therapy if their measured oxygen saturation is ≤88% or their partial pressure of oxygen is ≤55 mm Hg

A 55 year old male smoker has instituted lifestyle changes and been on 10 mg of atorvastatin (Lipitor) for 1 year without side effects. He presents today for follow up. His LDL has decreased from 195 to 130. His HDL and triglycerides are normal. Along with smoking cessation which of the following would be most appropriate according to national guidelines? a. No change in medication b. Add nicotinic acid c. Add fibric acid derivative d. Increase Lipitor to high intensity dosing

d. Increase Lipitor to high intensity dosing

Approximately 1/3 of world population infected with TB. It occurs disproportionately among

disadvantaged populations

You diagnosed a 60-year-old female with community acquired pneumonia, and determined that she is appropriate for outpatient therapy. She has a PMH of type 2 diabetes and ruptured her Achilles tendon when she took a fluoroquinolone for a UTI. What is the most appropriate medical therapy for her and why? a. High dose amoxicillin b. Azithromycin c. Ciprofloxacin d. Levofloxacin e. Amoxicillin and a macrolide

e. Amoxicillin and a macrolide Amoxicillin plus a macrolide would be the most appropriate medical therapy for this patient. Her comorbidity of diabetes puts her in the high-risk category needed expanded antibiotic coverage, so amoxicillin (even high dose) alone would be inadequate. A previous adverse effect when taking a fluoroquinolone would cause concern and the class of medication should be avoided if an alternative therapy exists. Cipro does not adequately cover pneumonia, and azithromycin is indicated for CAP in adults without comorbidities or risk of antibiotic resistant pathogens.

Seasonal influenza: common presenting symptoms

fever, chills, malaise, cough, coryza (inflammation of nasal mucous membranes), and myalgias

Oral Candidiasis (Thrush)

fungal infection of the oral mucous membranes caused by overgrowth of Candida albicans

Tricuspid regurgitation murmur

holosystolic, increases with inspiration, diseased RV

Goal for O2 therapy in COPD patients

increase baseline PaO2 to ≥ 60 mm Hg at rest, and/or produce SaO2 ≥ 90%, which will preserve vital organ function by ensuring an adequate delivery of oxygen.

Cervical adenitis

inflammation of one or more cervical lymph nodes

Typical causative organisms of seasonal influenzae

influenza a, b, c

Classification of asthma severity

intermittent persistent (mild, moderate, severe)

With suspected epiglottitis. Do not examine Pharynx unless

intubation equipment is available

Avoid_____________ in pt with allergy to peanuts or soy - it contains soy lecithin and may precipitate allergic reaction

ipratropium

FEV1/FVC ratio

is the % of FVC that can be expired in one sec. •75 - 80% is normal (Normal in asthma based on age, 70-85%) •60 - 75% demonstrates mild obstruction

Forced Expiratory Volume in 1 second (FEV1 )

is the amount of air a person can exhale in one second. • 80 - 120% of predicted is a normal value

Forced Vital Capacity (FVC)

is the total amount of air a person can exhale, usually measured in six secs •80 - 120% of predicted is a normal value •70 - 80% demonstrates mild reduction/restriction

What dietary pattern recommendations should be made for LDL-C reduction?

less trans fat, less sat fat with goal 5-6%, DASH diet, less animal products, sugar, meat, dairy, egg, butter, lard. Add soluable fiber and plant sterols.

Prescribe medication to which the likely pathogen is susceptible. Consider

local resistance patterns

Early in COPD you may only see reduced

mid-expiratory flow rate

Pertussis Diagnosis:

nasopharyngeal culture

PCSK9 inhibitors side effects

nasopharyngitis, URI, back pain, and injection site reactions.

Importance of HTN detection

o Increased risk of CVD associated with higher SBP/ DBP o 20 mm Hg higher SBP or 10 mm Hg DBP is associated with DOUBLING in the risk of death from stroke, heart disease or other vascular disease o Adults 45 yo without HTN have 40-yr risk for developing HTN (93% AA, 92% Hispanics, 86% whites, 84% Chinese) o HTN accounted for more CVD deaths than any other modifiable risk factor o SBP > risk factor than DBP

Resistant Hypertension defined as

o Patient takes 3 antihypertensive medications with complementary MOAs (diuretic included) but does not achieve BP control o When BP control is achieved but requires ≥4 medications

What groups should receive moderate intensity statin therapy?

o Pt with diabetes, age 40-75. LDL >70 mg/dl o Without DM but borderline-immediate ASCVD risk with risk enhancing factors for primary prevention.

Which individuals may benefit from the addition of ezetimibe?

o Very high risk existing ASCVD with LDL >70 o LDL >100 with primary hypercholesterolemia at baseline

In ACS 1/3 of pts will present with no/atypical chest pain. These patients are typically

older, female, diabetic

Tickle in throat, sensation of secretions in throat, frequent clearing of throat --Consider

postnasal drip/allergic rhinitis, sinusitis

Platelet inhibiting agents

prevent clots, coats RBC so they move through easier

Nitrates

promotes coronary dilation •Short acting - NTG tab or spray SL - always keep with patient •Take 5 min apart x 3 - unrelieved angina needs EMERGENCY evaluation •Long-acting patches, ointment, or oral medication •Monitor for hypotension; headache is frequent side effect •Tolerance easily developed, so nitrate free period should be encouraged •Do not use with ED drugs

Forced mid-expiratory Flow (FEF25-75 )

reflects small airway function •>80% is normal •60 - 80% reflects mild obstruction in the small airways

Over supplementation with O2 in COPD patients can result in

respiratory depression

Pertussis transmission

respiratory droplets adults are reservoir of disease with transmission to children -Adult immunization booster recommended: Tdap

treatment for seasonal influenzae

rest, fluids, analgesics possible cough suppressant, antivirals

Uncomplicated rhinosinusitis

rhinosinusitis without clinically evident extension of inflammation outside the paranasal sinuses and nasal cavity at the time of diagnosis

BP thresholds and recommendations for treatment and follow-up

see picture

Epley maneuver

see picture

bacterial rhinosinusitis

symptomatic inflammation of the paranasal sinuses and nasal cavity. The term rhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa

Chronic Rhinosinusitis

symptoms > 12 wks with or without exacerbations

aortic stenosis murmur

systolic: crescendo-decrescendo with radiation into neck, harsh

With any eye complaint, assess visual acuity, if visual acuity is affected,

the situation is urgent

Epiglottitis x-ray finding

thumb print sign

CAP: Typical presenting symptoms

varies depending on pathogen... symptoms consistent with CAP: fever, chills, pleuritic chest pain, productive cough with purulent sputum Typical symptoms: more likely to affect over 65, rapid onset, pathogens (S. pneumonia, H influenzae, & Klebsiella pneumonia) affects all part of lung lobe, more likely to have striking findings Symptoms: Appear very ill, sudden onset, high fever, shaking chills, pleuritic chest pain, SOB, productive cough, sputum changes from watery to bloody tinged, tachypnea, malaise

COPD management: Assess for comorbidities s/a

• CV disease- Most frequent and important comorbidity in COPD • Osteoporosis and anxiety/depression- often under-diagnosed and associated with poor health status and prognosis • Lung cancer- Frequent in patients with COPD and is the most frequent cause of death in patients with mild COPD • Serious infections- frequent in COPD patients • Metabolic syndrome and DM- Frequent in COPD and DM is likely to impact on prognosis.

Medication for those with EIB

• SABA 2-4 puffs of 5-60 minutes before exercise (Lasts 2-3 hrs) •LTRA or Cromolyn can be used prior to exercise (Duration 1-2 hrs) •Effective, but not recommended for frequent or long-term use: LABA @least 30 min before exercise (Last 10-12 hrs)

Activity for those with hx EIB

•6-10-minute warm-up before starting activity •Wear medical alert bracelet or let someone else know about condition •Education - able to participate in activities, but may need inhaled medication before activity

Initial BP meds for Heart failure with preserved EF

•ACE inhibitors, ARBs, beta blockers ***avoid CCBs in HF with reduced EF

Chronic PAD s/s

•Aching of lower extremity •Fatigue with activity relieved by cessation (intermittent claudication) •Pale, cool, diminished pulses in extremity •Absent or decreased hair and nail growth of LE •Color changes - pale with elevation, dependent rubor •Doppler ultrasound or angiography

Subconjunctival hemorrhage: Management

•Acute Treatment -Self-limiting - no treatment required unless associated conjunctivitis -Warm compresses and eye lubricants may be useful •Referral to Ophthalmologist if -Suspicious or serious injury with history of blunt trauma -Visual disturbance -Unresolved within 2 weeks •Future management -Control BP, blood glucose, INR -Protective eyewear

COPD exacerbation defined as

•Acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication

Risk factors for CAP

•Advanced age •Alcoholism •Tobacco use •Comorbid medical conditions - Particularly asthma & COPD •Immunosuppression

Risk factors for cataracts

•Aging •Cigarette smoking •Ultraviolet B sunlight exposure •Diabetes, metabolic syndrome •Prolonged high-dose steroids •Positive family history •Malnutrition and physical inactivity •Alcohol consumption

COPD physical activity recommendations

•All COPD patients benefit from regular physical activity- Encourage routinely! •Exercise Testing objectively measures exercise impairment •Assessed by a reduction in self-paced walking distance or during incremental exercise testing in a laboratory •Powerful indicator of health status impairment and predictor of prognosis

Initial BP meds in Diabetes

•All first-line agents (diuretics, ACE inhibitors, ARBs, CCBs) are useful and effective. •ACE inhibitors or ARBs may be considered first in the presence of albuminuria

Importance of differentiating between virus and strep

•Antibiotic stewardship •Avoid sequela of untreated GABHS - - rheumatic fever, glomerulonephritis

ACS: what to do during transport

•Aspirin - chewed •Oxygen •Pain Relief - NTG, Morphine •Beta blocker if not contraindicated •IV- antecubital fossa if possible

Evaluation and treatment for unexplained ALT > 3x ULN

•Assess current medications and alcohol use •Assess for hepatitis, other liver disease •Physical exam, liver ultrasound, biopsy

COPD management

•Assess symptoms (Dyspnea, cough, sputum) •Assess degree of airflow limitation using spirometry •Assess risk of exacerbations •Assess for comorbidities

Moderate intensity statins

•Atorvastatin 10-20 mg •Rosuvastatin 5-10 mg •Simvastatin 20-40 mg •Pravastatin 40-80 mg •Lovastatin 40 mg •Fluvastatin 40 mg BID •Fluvastatin XL 80 mg •Pitavastatin 1-4 mg

High intensity statin

•Atorvastatin 40-80 mg •Rosuvastatin 20-40 mg

Macrolides in CAP

•Azithromycin - Zpac is 500 mg day 1, 250 mg x 4 days •Clarithromycin (Biaxin) - Patients frequently complain of GI upset

Proper BP Measurement

•BP in both arms at 1st visit •Use arm with higher reading for subsequent readings •Separate repeated measurements by 1-2 min. •Inflate cuff 20-30 mm Hg above palpated estimate of radial pulse obliteration. •Deflate the cuff pressure 2 mm Hg per second, and listen for Korotkoff sounds.

Epiglottitis: Etiology

•Bacterial, fungal, viral •Traumatic •Allergic

Initial BP med with Stable Ischemic Heart Disease

•Beta blockers, ACE inhibitors, ARBs •Add CCBs, thiazide -type diuretic if needed

Hyphema: etiology

•Blunt or penetrating eye injury -Fist, elbow, air bag deployment, baseball, fall, etc. •Intraocular surgery •Spontaneous - tumors, vascular abnormalities, coagulation disorder

Hyphema: Risk factors

•Blunt trauma to eye •Anticoagulant therapy •Hemophilia or sickle cell anemia

Aphthous ulcers: Assessment findings and symptoms

•Burning sensation, hurts to eat and swallow, especially food and drink with high acid content •Localized round to oval ulcer with grayish base surrounded by red halo

HSV Stomatitis: Assessment findings and symptoms

•Burning, then small vesicles that rupture and form scabs or gray ulcers •Swollen erythematous, friable lesion

Varicose veins symptoms and PE findings

•Can be asymptomatic •Dull aching heaviness and fatigue in legs •Assess with patient standing •Dilated deep blue/purple tortuous veins beneath the skin •May result in chronic venous insufficiency and venous stasis

Assessment of COPD Exacerbation

•Change in frequency/severity of dyspnea, cough, and sputum production •Sputum volume and color (Purulent sputum may need empirical antibiotic treatment) •Limitation of daily activities •Recent exposure to pathogens/irritants •Physical examination including vital signs •ABGs: PaO2 < 60 mm Hg w/ or w/o PaCO2 > 50 mm Hg on room air indicates respiratory failure •CXR: useful to exclude alternative diagnoses •ECG: may aid in the diagnosis of coexisting cardiac problems •CBC: identify polycythemia, anemia or bleeding •Metabolic profile: electrolyte disturbances, DM, poor nutrition •Spirometry: not recommended during an exacerbation

subconjunctival hemorrhage: Physical exam

•Check BP •Normal appearing external eye with no discharge, PERRLA, normal Fundoscopic exam •Blood under part or entire conjunctiva usually unilateral •Diagnostics -Fluorescein stain if foreign body or corneal abrasion suspected -Consider bleeding disorder work up if repeated episodes

Red flags: MI

•Chest pain, pressure, heaviness for ≥ 20 mins unrelieved by rest or NTG •Radiates to jaw, arm, neck •Accompanied by nausea, vomiting, diaphoresis, or dyspnea•Atypical presentation •Women with new onset fatigue or shortness of breath •Jaw, neck, arm or back pain without chest pain

High intensity statin in ages 40-75

•Clinical ASCVD •Severe primary hypercholesterolemia (LDL-C level ≥ 190 mg/dL) •High 10-year ASCVD risk for primary prevention •With DM and multiple risk factors or age 50-75

Pharyngitis/Tonsillitis: Risk factors

•Communal living •Immunosuppression •Excess alcohol consumption, smoking, receptive oral sex

Hyphema: Physical Assessment

•Comprehensive eye exam •Open globe injury - integrity of the outer membranes of the eye is disrupted •Visual acuity •Photophobia •Direct and consensual response of pupils and associated pain •Blood fluid level line in anterior chamber •Eye firmness •Neuro exam •Other signs of bleeding

Chronic venous insufficiency tx

•Compression stockings before ambulation •Elevate FOB •Avoid prolonged standing or inactivity •Ambulatory exercise to increase venous return •Weight reduction if applicable •Diuretic therapy ONLY with obvious fluid overload •Hydrocortisone or triamcinolone for itching •Antibiotic for positive wound culture of ulcer •Ulcer will not heal if edema is uncontrolled

Corneal abrasion: Physical exam

•Conjunctival injection, photophobia, increased lacrimation on affected side •Altered integrity of cornea •Irregular light reflex •Abrasion may be visible to naked eye or require fluorescein staining •Visual acuity may be affected if abrasion is centrally located •PERRLA, Fundoscopic exam is normal •Evert upper and low eye lid to assess for foreign body

Consider Pulmonology referral in asthma when

•Consider consultation with pulmonologist at Step 3 treatment, definitely at Step 4 in adults •Patient not meeting goal of treatment after 3-6 months of therapy •Uncontrolled co-morbid conditions (GERD, allergies, COPD, infections) complicating asthma •Immunotherapy as a treatment consideration •Continuous use of oral corticosteroid therapy, high-dose inhaled corticosteroids or 2 bursts of oral corticosteroid in 1 year •Occupational or environmental inhalant aggravating asthma

Evaluation of LDL >/= 190

•Consider secondary causes

Opioids in COPD management

•Consider trial of opioids with severe dyspnea despite optimal medical mgmt •Sedative-hypnotic drugs (diazepam) are controversial in intractable dyspnea, but may benefit very anxious patients

Corneal Abrasion: Risk Factors

•Contact lens wear •Foreign body in eye •Abrasive injury •Lack of protective eyewear •Contact sports •Blepharitis or entropion •Dry eye syndrome •Autoimmune disorders •Chronic corneal exposure (Bell's palsy, exophthalmos) •Chronic steroid use •Flash burn

HSV Stomatitis "cold sore"

•Contagious, recurrent •Usual location - Buccal mucosa, anterior tonsillar pillars, lips, tongue, gingiva

DVT diagnostic tests

•D-dimer, CBC, platelets, PT/INR, PTT •Ultrasound •Contrast venography- Gold standard •Impedance plethysmography •indirect assessment of blood-volume changes in the body by measurement of the blood's electrical impedance •Magnetic resonance venography

Asthma Special Considerations

•Deaths 3 x greater in blacks & Hispanics than whites in US •Use asthma medications with caution in elderly - often do not tolerate side effects and have difficulty using inhalers •Be aware of coexisting heart disease, osteoporosis, liver and kidney disease, which can be aggravated by asthma meds •Beta blockers may induce or worsen bronchospasms •Avoid ipratropium in pt with allergy to peanuts or soy - it contains soy lecithin and may precipitate allergic reaction

Endocarditis ppx only for certain procedure s/a:

•Dental: manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa •Respiratory tract procedures involving incision of respiratory mucosa •Procedures on infected skin, skin structure, or musculoskeletal tissue **No prophylaxis for GU or GI procedures

Evaluation and treatment for TGs >500

•Diet - avoid alcohol, simple sugars, refined starches, saturated and trans fatty acids, restrict total calories •Niacin, fibric acid derivative, statin

Percentage reduction in LDL-C relative to baseline levels

•Diet modification - 10-15 % •Moderate intensity statin - 30-49% •High intensity statin - 50 % or more •Ezetimibe or bile acid sequestrant - 15-25% reduction •PCSK9 inhibitors - ~ 60%

Keratitis: PE findings

•Diffuse redness with ciliary flush •Constructed pupil •Eye discharge •Pain •Photophobia •Vision loss •Typically unilateral

Epistaxis: Management

•Direct pressure just below bridge of nose x 10-15 min -Sitting, leaning forward •Insert cotton ball moistened with a short-acting topical vasoconstricting agent (phenylephrine, oxymetazoline, 4% cocaine solution, 1:1000 epinephrine) into nares and apply pressure x 5-10 min •May use silver nitrate sticks to site of bleed if visible •Nasal tamponade -Anterior nasal packing with petroleum gauze •Referral for non-responsive or recurrent bleeds

Describe treatment options for anterior epistaxis:

•Direct pressure just below the bridge of the nose x 10-15 minutes. Sitting, leaning forward •Insert cotton ball moistened with a short-acting topical vasoconstricting agent (phenylephrine, oxymetazoline, 4% cocaine solution, 1:1000 epinephrine) into nares and apply pressure x 5-10 minutes •May use silver nitrate sticks to site of bleed if visible Nasal tamponade- anterior nasal packing petroleum gauze.

Conjunctivitis: PE

•Document visual acuity -Blurred vision should clear with blinking •Pupillary reaction and EOM normal •Typical -Edema of eyelids -Exudate/matting of eyelashes -Conjunctival injection •Check for symptoms of systemic disease - rash, lesions, joint pain, fever, GU complaints •Should find absence of ciliary flush, corneal changes, pupil abnormalities and photophobia in simple conjunctivitis

Cervical adenitis: Assessment

•Duration, Onset, Tenderness, Warmth, Change in size •Thorough exam of ears, nose, and throat •Assess all lymph nodes -Are nodes soft, firm, hard, matting, adherence to skin, fluctuant, unilateral or bilateral •Differentiate from thyroid gland

Consider COPD as diagnosis in any individual over 40 with any of the following:

•Dyspnea (Progressive, Worse with exercise, Persistent) •Chronic cough--Even if intermittent and unproductive •Chronic sputum production--In any pattern •History of exposure to risk factors -Tobacco smoke -Cooking or heating fuels -Environmental exposure •Family history of COPD

Essential Hypertension (95% of hypertensive patients)

•Elevated BP from complex interactions between multiple genetic and environmental factors •Onset between ages 25 and 50 •Greater prevalence in black (20-30%) vs. white (10-15%) adults in the US Exacerbating factors •Obesity, stress, excess sodium intake, low potassium intake, smoking, lack of aerobic exercise, excessive ETOH intake, substance use (i.e. cocaine, caffeine, etc.), NSAID therapy, metabolic syndrome

Consider fasting lipid profile for the following situations

•Elevated TG (≥ 400) in initial lipid profile •Clinical ASCVD •Family history of premature ASCVD or genetic hyperlipidemia

Cervical adenitis: When to refer

•Emergency dept if Node enlargement interferes with swallowing or breathing •To ENT surgeon if -Malignancy suspected -Lymphadenitis persists for 4 weeks or more

Pharyngitis/Tonsillitis: Exam

•Enlarged tonsils, pharyngeal erythema •Tonsillar or pharyngeal exudates •Soft palate petechiae •Cervical adenopathy •Fever •Scarlet fever rash •Gray pseudomembrane •Conjunctivitis •Rhinorrhea

Chalazion: Etiology/Presentation

•Etiology: Noninfectious obstruction causing extravasation of irritating lipid material in the eyelid soft tissues with focal secondary granulomatous inflammation. •Presentation -Typically a more slowly developing etiology -Located further from the eyelid's edge, usually larger than a stye and painless -Initial diffuse swelling of eyelid then nontender nodule or lump localizes to the body of the eyelid. May drain through the inner surface of the eyelid or be absorbed spontaneously over 2 to 8 weeks -Visual acuity unaffected

Hordeolum: etiology/presentation

•Etiology: Typically pyogenic (typically staphylococcal) infection or abscess •Presentation -Often rises close to the edge of one of the eyelids -Tender and possible tearing, photophobia, and a foreign body sensation. -Typically, a small yellowish pustule develops at the base of an eyelash, surrounded by hyperemia, induration, and diffuse edema. Within 2 to 4 days, the lesion ruptures and discharges material (often pus), thereby relieving pain and resolving the lesion. -Visual acuity unaffected

Lipid management for patients >75

•Evaluate potential ASCVD risk reduction, adverse effects, drug-drug interactions, patient frailty, patient preferences •LDL-C of 70-189 mg/dL -may initiate moderate intensity statin •Clinical ASCVD -Initiate or continue moderate to high intensity statin •Diabetes -Continue statin therapy if tolerated •Discontinue statin if -Functional decline, multimorbidity, frailty or reduced life-expectancy limits potential benefits of statin therapy

CAD: Diagnostic tests

•Exercise stress- ST depression •Thallium myocardial imaging - hypoperfusion •Coronary angiography - definitive

Corneal Abrasion: Hx and symptoms

•Eye pain, inability to open eye, photophobia, tearing, foreign body sensation, blurred vision, conjunctival injection •Unilateral •History of contact lens use, dry eyes, trauma, foreign body, chemical burn

Blepharitis: PE

•Eyelid erythema, inflammation, change in eyelash pattern •Seborrheic - dandruff-like flaking, scaling, waxy surface of lid margin •Infectious - purulent discharge, concurrent papules or pustules, punctate ulcerations •Visual acuity unaffected - cornea and pupil exam normal

The FEV1/FVC ratio is helpful in deciding whether there is obstructive or restrictive disease.

•FEV1 /FVC ratio is lower than expected (usually < 75%), this indicates obstruction. •FEV1/FVC ratio is normal but the FVC is decreased, this indicates restrictive disease. •Both the FVC and the FEV1/FVC are reduced, this may mean that there are both restrictive and obstructive components to the problem

Risk factors for angle closure glaucoma

•Family history •Age >60 years •Female •Hyperopia •Medications - antihistamines, adrenergic agents, antipsychotics, antidepressants, anticholinergics •Asian or Inuit descent

Risk enhancing factors for ASCVD

•Family history of premature ASCVD -(males, age <55 y; females, age <65 y) •Primary hypercholesterolemia -LDL-C 160-189 mg/dL -non-HDL-C 190-219 mg/dL •Metabolic syndrome(at least 3 factors present) -increased waist circumference -elevated triglycerides [>150 mg/dL, nonfasting] -elevated blood pressure -elevated glucose -low HDL-C [<40 in men; <50 mg/dL in women] •Chronic kidney disease -eGFR 15-59 mL/min with or without albuminuria; not treated with dialysis or kidney transplantation •Chronic inflammatory conditions -Psoriasis, RA, lupus, or HIV/AIDS •History of -premature menopause (before age 40 y) -pregnancy-associated conditions that increase ASCVD risk, such as preeclampsia •High-risk race/ethnicity •Lipids/biomarkers associated with increased ASCVD risk •Persistently elevated primary hypertriglyceridemia -≥175 mg/dL, nonfasting •Elevated hsCRP ≥2.0 mg/L •Elevated Lp(a) ≥125 nmol/L •Elevated apoB ≥130 mg/dL •Ankle Brachial Index < 0.9

What are the 4 clinical features most predictive of Group A beta-hemolytic strep pharyngitis (GABHS)?

•Fever > 38c/100.4f •Tender anterior cervical adenopathy •Lack of cough •Pharyngotonsillar exudate

Seasonal influenza symptoms

•Fever, chills, malaise, myalgias •Headache, nasal stuffiness •Nonproductive cough, sore throat •Geriatric presentation may include confusion with minimal physical symptoms

Symptoms consistent with CAP

•Fever, chills, pleuritic chest pain, productive cough with purulent sputum •Lack of fever and sputum significantly reduce likelihood of CAP in outpatients •Geriatric presentation may be different

BP treatment in the elderly

•For older adults (≥65) with HTN and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. •BP lowering is reasonable to prevent cognitive decline and dementia.

Corneal abrasion: differentials

•Foreign body, iritis, keratitis, corneal ulcer

subconjuntival hemorrhage: Hx taking/Symptoms

•Generally asymptomatic •Sudden appearance of blood in eye, sometimes on waking •Ask about trauma, contact lens usage, cataract surgery, comprehensive medical history •No pain or vision changes

Cataracts: Prevention and Screening

•Glasses with ultraviolet protection •Antioxidants such as Vitamins C and E •Avoid tobacco products •Control of diabetes •Judicious use of corticosteroids •Screening with every annual eye exam starting at age 40

Aphthous ulcers: Management

•Good oral hygiene, avoid exacerbating factors •Pain control - swish and spit 2% viscous lidocaine, liquid diphenhydramine 12.5 mg, Aluminum hydroxide, magnesium hydroxide, or simethicone suspension •No single systemic treatment has proven efficacy •Topical steroids in an adhesive base

Lipid management for Secondary ASCVD Prevention Ages 40-75, Existing ASCVD

•High intensity statin therapy Goal: 50% reduction in LDL-C •If intolerant, then Moderate intensity statin with goal of 30-49% reduction in LDL-C •Very high risk with LDL-C 70 mg/dL or higher -Maximally tolerated statin -Ezetimibe -PCSK9 inhibitor therapy

Cataracts: Assessment and management

•History -Painless progressive decline in vision, typically bilateral -Problems with night driving, reading road signs or fine print -Increased falls, injuries or accidents possibly due to vision •Physical Exam - important to have dilated eye exam routinely -Altered red reflex, clouding of lens -Visual acuity change -Refer to Ophthalmology - requires surgery

Clinical ASCVD defined

•History of MI •Stable or unstable angina •Coronary or other arterial revascularization •Stroke or TIA •Peripheral artery disease •Aortic aneurysm

DVT treatment

•Hospitalize for IV heparin therapy OR •Outpatient treatment for uncomplicated DVT -LMWH + warfarin 5 mg -Continue dual therapy for 5 days and until INR is 2-3 -Length of treatment based on contributing factors and patient risk -PT INR to monitor warfarin therapy

Hordeolum: Tx

•Hot compresses 5- 10 mins BID/TID •Ophthalmic antibiotics -Topical to eyelid margin 7-10 days -Systemic for 2 weeks if refractory to topical antibiotics or preseptal (periorbital) cellulitis present

Chalazion: Tx

•Hot compresses 5-10 mins BID/TID •Often resolve without intervention over days to weeks. •Antibiotics are not indicated since chalazion is a granulomatous condition. •Persistent lesions should be treated by an ophthalmologist with incision and curettage or glucocorticoid injection

Inhaled Corticosteroids (ICS) are NOT 1st line treatment and NOT for monotherapy in COPD patients. For patients with FEV1 < 60% predicted, ICS improves sx, lung function, quality of life, and reduces frequency of exacerbations •HOWEVER - associated with increased risk of pneumonia

•ICS combined with a LABA is more effective than either individual component for patients with mod-severe COPD •Still associated with increased risk of pneumonia •Addition of a LABA/ICS combination to an anticholinergic (tiotropium) appears to provide additional benefits. •Withdrawal from ICS can lead to exacerbations •Use of oral corticosteroids is controversial apart from acute exacerbations •Long-term treatment with oral corticosteroids is not recommended

Bronchodilators are first line for all COPD patients. They are central to symptom management in COPD, but do not alter the decline in lung function.

•INHALED bronchodilators are preferred over oral •Formulations: Short-acting prn -SABA or anticholinergic/antimuscarinic Long-acting regularly -LABA or anticholinergic/antimuscarinic -More convenient and effective than short-acting for symptom control -Reduce exacerbations and related hospitalizations and improve symptoms and health status. Combination of beta 2 agonist and anticholinergic -Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator. For patients not controlled on inhaled bronchodilator therapy, theophylline may be considered -Narrow therapeutic index

Hyphema: Management

•Immediate Transport to ER or Ophthalmologist •Minimize eye movement and pressure -Non pressure eye patch to limit movement -Keep patient upright during transfer -Limit activity - no "screen" viewing or reading •Potential complications -Decreased visual acuity -Recurrent bleeding -Retinal detachment

Oral Candidiasis (Thrush): Risk Factors in Adults

•Immune deficiency - especially HIV •Denture wear •Use of inhaled corticosteroids •Diabetes, Malnutrition, Obesity

Uveitis, Iritis, Keratitis; Risk Factors

•Immunocompromised •Autoimmune and inflammatory conditions •Contact lens wear •HSV history or close contact

Reversibility of airflow obstruction is defined by

•Increase of ≥ 12% and 200 ml in FEV1 after bronchodilator •Increase of ≥ 15% and 200 ml in FVC after bronchodilator

Conjunctivitis: risk factors

•Increased incidence in fall due to higher incidence of viral infections and exposure to seasonal allergens •CONTAGIOUS •Contact lens - especially overnight •Sexually transmitted disease contact •Exposure to infectious agents, chemical agents, wind, extreme temperatures, allergens

Phospodiesterase-4 inhibitor (PDE-4): Roflumilast (Daliresp)

•Increases intracellular cyclic adenosine monophosphate in lung tissue; reduces sputum neutrophils and eosinophils •No bronchodilator effects •Treatment to reduce the risk of COPD exacerbations in patients with severe and very severe COPD and a history of exacerbations and chronic bronchitis. •Lots of potential side effects!

Conjunctivitis: Etiology

•Inflammatory processes causes dilation of blood vessels, edema, and exudate of conjunctival membrane Bacterial •Chlamydia Trachomatis •Neisseria Gonorrhea •S. Aureus •Streptococci •N. Gonorrhea Viral •Adenoviruses •Herpes Simplex •Herpes Zoster Allergic •Seasonal allergens •Chemical exposure •Smoke •Contaminated eye makeup or eye drops •Contact lenses Systemic disease •Sjogren's syndrome •Wegener's granulomatosis

Hyphema: History

•Injury details •Eye pain, vision •Nausea, vomiting •Patient or family history of hemophilia, blood disorders, medication (especially ASA, NSAIDs, herbals)

Allergic Rhinitis: Treatment

•Intranasal Corticosteroid Sprays -Very effective and available OTC -Delay of relief onset by 2 or more weeks -Tilt head forward and aim spray back and toward the ear on the same side as nostril avoiding septum •Anti-histamines -Temporary but immediate relief of symptoms -Sedating - Diphenhydramine, brompheniramine, chlorpheniramine -Non-Sedating - Loratadine, desloratadine, fexofenadine, cetirizine** •Azelastine nasal spray •Anti-leukotriene meds -Montelukast - - Monotherapy or with loratadine or cetirizine

Left ventricular failure

•LV unable to pump blood to body tissues •Low CO, pulmonary congestion •Often the result of CHD, MI, valvular heart disease, cardiomyopathies, hypertensive heart disease

Risk factors for Epiglottitis

•Lack of immunization with H influenza type B vaccine •Immunocompromise •Comorbidities (HTN, DM, substance abuse)

neti pot

•Lean over a sink, tilt your head sideways with your forehead and chin roughly level to avoid liquid flowing into your mouth. •Breathe through your open mouth, insert the spout of the saline-filled container into your upper nostril so that the liquid drains through the lower nostril. •Clear your nostrils, then repeat the procedure on the other side •Provide good instructions to patients -Proper technique to prevent aspiration -Type of water to use -Adverse effects to watch for

Atypical bacteria in CAP- intrinsic resistance to beta-lactams and inability to be visualized on Gram stain or cultured using traditional techniques

•Legionella species - spread through contaminated water/mist source such as air conditioning, pool/spa •Mycoplasma pneumoniae - Cough transmitted, seen in those who spend time in close proximity to others

Respiratory Fluoroquinolones in CAP

•Levofloxacin (Levaquin) 500 mg daily x 10-14 days or 750 mg x 5 days •Moxifloxacin (Avelox) 400 mg daily x 7-14 days •Gemifloxacin (Factive) 320 mg daily x 5-7 days •NOTE - though ciprofloxacin is a fluoroquinolone, it is NOT a respiratory fluoroquinolone, and NOT recommended in the treatment of pneumonia due to poor respiratory performance •Risk of tendinitis/tendon rupture in older adults reported•Reduce dose in renal impairment

Baseline screening for lipids in healthy adults 20 years or older and not on lipid-lowering therapy

•Lipid Profile - fasting or nonfasting for baseline •Ask about fatty meal intake in the preceding 8 hours

Cervical adenitis: Etiology

•Local infection - dental disease, URI, otitis media, pharyngitis, stomatitis •Systemic infection - viral or bacterial •Cat-scratch disease, toxoplasmosis •Neoplasms -80% of isolated solitary neck masses in adult > 40 years of age -Risk factors are tobacco and alcohol use •Autoimmune disorder

Mono: Assessment

•Low-grade temp, fatigue, sore throat, headache •Marked posterior cervical/occipital lymphadenopathy •White/purple tonsillar exudate •Palatal Petechiae •Splenomegaly, possible hepatomegaly

Asthma Basics

•Make the diagnosis with spirometry -Decreased FEV1/FVC = obstruction ->12% increase in FEV1 or FVC = reversibility •Classify Asthma Severity and start treatment -All intermittent asthma gets SABA rescue inhaler -All persistent asthma - ICS plus reliever therapy -Steps 3 and 4 - SMART therapy •Treat Co-Morbid conditions (GERD, obesity, allergies) •Educate -Avoid triggers -Self management -Written Asthma Action Plan •Routine Follow up -Specific questions to determine control -Step up, step down or maintain treatment based on control -Spirometry to monitor lung function

Sensorineural hearing loss

•Malfunction in cochlea or cochlear portion of CN VIII -Progressive loss with advancing age -Excess noise exposure -Head trauma -Systemic dz or Meds •Typically not correctable

When to consider admission for COPD exacerbation

•Marked increase in intensity of symptoms •Severe underlying COPD •Onset of new physical signs •Hemodynamic instability •Failure of exacerbation to respond to initial medical management •Significant co morbidities •Frequent exacerbations •Older age •Insufficient home support

DVT assessment

•May be asymptomatic •Unilateral leg pain or tenderness of calf •Reproducible tenderness with calf compression - Homan's sign •Leg circumference greater than uninvolved leg •Swelling, discoloration

How does treatment of mild and moderate otitis externa differ?

•Mild: topical drops (acetic acid with hydrocortisone •Moderate: topical antibiotic with steroid (cipro HC or Cortisporin) -To ensure medication delivery to entire canal **Use direct visualization/curette/cotton swab to remove cerumen, desquamated skin, and drainage from EAC . If TM is intact, EAC can be irrigated with a 1:1 dilution of 3% hydrogen peroxide and water **Wick placed in EAC for topical medication application if needed

Lipid management for Patients with Diabetes Ages 40-75, DM

•Moderate intensity statin •Multiple ASCVD risk factors or ages 50-75 -Consider high intensity statin - Goal: 50% reduction in LDL-C •10-year ASCVD risk of 20% or higher -Add ezetimibe to maximally tolerated statin therapy •Ages 20-39 with diabetes-specific risk enhancers -DM of long duration (≥ 10 years type 2 or ≥ 20 years type 1), albuminuria, eGFR < 60, retinopathy, neuropathy or ABI < 0.9 -Consider statin therapy

Mono: Diagnostics

•Mono-spot - false-negative rates highest early in disease - (25% 1st wk; 5-10% 2nd wk, 5 % 3rd wk) •EBV antibody titer - GOLD STANDARD •CBC - Lymphocytosis (> 50%) and elevated WBC (10-20,000) •Throat culture to rule out concomitant GABHS infection

Antibiotics in COPD management

•Most beneficial in exacerbations associated with dyspnea and a change in the quantity or character of sputum •The use of prophylactic antibiotics in COPD has not been shown to be beneficial •Give more consideration to use in more severe disease or frequent exacerbations •Antimicrobial therapy choice should be based on local bacterial resistance patterns and suspected organisms

Open-angle glaucoma

•Most common in US (90% of cases) •Slow progressive peripheral visual field loss followed by central field loss usually in the presence of elevated IOP. •Increased aqueous production and/or gradual decreased outflow are possible mechanisms for elevated IOP

Concurrent symptoms that may be present in asthma

•Nasal mucosal swelling, rhinitis, nasal polyps, allergic shiners •Eczema, atopic dermatitis

Epistaxis: Etiology

•Nasal trauma •Nose Picking, foreign bodies, forceful nose blowing, fracture, abuse of inhaled recreational drugs •Local irritation due to secondary condition (low humidity, supplemental oxygen, URI, Rhinitis) •HTN •Septal deviation or perforation

Consequences of COPD exacerbations

•Negative impact on quality of life •Impact on symptoms and lung function •Accelerated lung function decline •Increased Mortality •Increased economic costs

Cough suppressants in COPD management

•Not recommended in stable COPD •Cough is troublesome but has a significant protective role

Bacterial conjunctivitis: Presentation

•Often starts in one eye and spreads to both •Occasionally associated with sore throat or fever •Profuse exudate •Conjunctival chemosis/edema •Generalized eye hyperemia •Moderate eyelid edemaModerate tearing •Preauricular adenopathy less likely •Pruritus - mild if present

Risk factors for open angle glaucoma

•Older age •Black race •Family history •Elevated IOP •Myopia •Diabetes •Prolonged use of corticosterioids •Cardiovascular disease •Hypothyroidism

Pharyngitis/Tonsillitis: history taking

•Onset, fever •Sore throat, hoarseness •Cough, lower respiratory symptoms •Fatigue, anorexia, nausea •Headache •Upper respiratory symptoms

AOM management: Adjunctive therapy

•Oral Decongestants - pseudoephedrine or phenylephrine •Topical decongestants for 3 days •Analgesic for ear pain - NSAIDs or acetaminophen •Saline nasal spray •Steroid nasal spray if allergic component •Auto-insufflation

AOM: Symptoms

•Otalgia, aural pressure, decreased hearing, +/- fever, recent URI •Pain relieved by sudden "pop" may indicate TM rupture

Patients Who Might Benefit from Knowing Their CAC Score

•Patients reluctant to initiate statin who wish to understand their risk and potential for benefit more precisely •Patients concerned about need to reinstitute statin therapy after discontinuation for statin-associated symptoms •Older patients (men 55-80 y of age; women 60-80 y of age) with low risk factors who question whether they would benefit from statin therapy •Middle-aged adults (40-55 y of age) with calculated 10-year risk for ASCVD 5% to <7.5% with other factors that increase their ASCVD risk, although they are in a borderline risk group.

GABHS treatment

•Penicillin V 500 mg BID x 10 days •Cefuroxine 250 mg BID x 5-10 days •Erythromycin 500 mg BID x 10 days •Azithromycin 500mg qd x 3 days

Pharyngitis/tonsillitis: treatment

•Peritonsillar abscess requires urgent referral •Warm saltwater gargles •OTC analgesics - acetaminophen or NSAIDs •Throat lozenges •Cool-mist humidifier

Bacterial Rhinosinusitis: Dx

•Persistence of symptoms more than 10 days after onset •Worsening of symptoms within 10 days after initial improvement •Imaging (sinus xray/non-contrast coronal CT) is not recommended for routine presentation. Only indicated if -Complicated dental infection -Non-responsive to therapy -Repeated presumed bacterial rhinosinusitis infections -Intracranial involvement or CSF rhinorrhea is suspected -Concerning atypical presentation

When should acute bacterial rhinosinusitis (ABRS) be treated with antibiotics?

•Persistent >10 days •Severe symptoms (severe fever, facial pain, swelling of face) •complicated (immunodeficiency)

Disorders of the mouth and pharynx: Non-infectious causes

•Persistent cough •Postnasal drip •Gastroesophageal reflux disease •Acute thyroiditis •Neoplasm •Allergies

Epistaxis: Careful assessment, including

•Precipitating events •Labs: CBC, PT and PTT •Other bleeding - coffee-ground emesis, hemoptysis, melena •Current medications •BP •ENT exam

Viral conjunctivitis: Presentation

•Profuse tearing •Generalized eye hyperemia •Preauricular lymphadenopathy •Occasional association with sore throat and fever •Minimal exudate •Minimal pruritus

Cataract

•Progressive painless clouding of lens - results in localized or generalized vision loss or blindness •Leading cause of blindness worldwide •Etiology -Protein changes in the normally transparent lens cause opacity and light scattering -Age related - 90% of cause -Congenital -Ocular trauma, infectious or inflammatory conditions -Secondary to systemic disease (DM, thyroid, parathyroid, sarcoid, atopic dermatitis) -Systemic or inhaled corticosteroids -Radiation of infrared heat exposure

Endocarditis ppx for high risk patients such as:

•Prosthetic cardiac valve •Previous infective endocarditis •Unrepaired cyanotic congenital heart disease •Including palliative shunts and conduits •Completely repaired congenital heart defects with prosthetic material during the first 6 months post repair •Repaired congenital heart defects with residual defects at site of prosthetic material •Heart transplant patients who developed significant valve disease

Right ventricular failure

•RV unable to pump venous return to lungs, left heart •Systemic congestion and low CO from LV •Often result of LV failure, RV infarct, COPD, pulmonary HTN

Red flags: Arrhythmia

•Rapid heart rate •Hypotension •Dyspnea

Pharyngitis/tonsillitis: Diagnosis

•Rapid strep antigen screen - may send culture if negative •Throat culture - gold standard for diagnosis •Monospot if mononucleosis suspected

Risk Factors for AOM

•Recent URI •Allergies •Anatomic Anomaly •Cigarette use or exposure to second hand smoke

Proper BP documentation

•Record SBP and DBP. •Note the time of most recent BP medication taken before measurements. •Use average of ≥2 readings obtained on ≥2 occasions to estimate individual's BP.

COPD management/Goals

•Reduce Symptoms: Relieve symptoms, Improve exercise tolerance, Improve health status •Reduce risk for exacerbation: Prevent disease progression, Prevent and treat exacerbations, Reduce mortality

Non-pharmacologic management of allergic rhinitis

•Reduce exposure to allergens •Air purifiers / Dust filters •Allergy testing •Refer to allergist for consideration of immunotherapy/Desensitization

Cervical adenitis: Differentials

•Result of localized infection - often anterior cervical and submandibular, tender, and bilateral •Parotitis - nodal pain with eating •Malignancy - gradual onset and enlargement, non tender, firm, matted, no infection present

Oral Candidiasis: Prevention

•Rinse mouth after inhaled steroid use •Clean, well-fitting dentures •Blood glucose control, Weight loss, Proper nutrition

Bacterial rhinosinusitis: common pathogens

•S. pneumoniae •Other streptococci •H. influenza

ACS range from unstable angina to acute myocardial infarction classified based on presenting electrocardiogram

•ST segment elevation (STEMI) •Non ST segment elevation

Allergic asthma triggers

•Seasonal/Environmental allergens •House dust mites, cockroach excrement, cat dander, pollens, molds

Most respiratory infections are viral. Antibiotics only with

•Secondary bacterial infection •Underlying respiratory condition •Prolonged symptoms

Allergic conjunctivitis: Presentation

•Severe itchy eyes •Moderate tearing •Stringy discharge •Usually bilateral •Generalized eye hyperemia •Chemosis/conjunctival/eyelid edema •Cobblestone appearance •Rhinitis, sneezing, seasonal or dander allergies •Minimal exudates •Not associated with sore throat or fever

During statin therapy

•Severe unexplained muscle symptoms or fatigue -Discontinue statin -Consider rhabdomyolysis (CK, CR, UA for myoglobinuria), check hepatic panel •Mild to moderate muscle symptoms -Discontinue statin and evaluate for other conditions (hypothyroidism, impaired renal/hepatic function, rheumatologic disorders, vitamin D deficiency) -Restart low dose of another statin (statin challenge) after symptoms resolve

Allergic rhinitis (Hay fever): S/s

•Similar to Viral Rhinitis but persistent and often related to allergen exposure with seasonal variation •Clear rhinorrhea, sneezing, tearing, eye irritation, allergic shiners •May also see cough, bronchospasm, eczematous dermatitis •Pale, violaceous, or gray mucosa due to venous engorgement •Nasal polyps are associated with long-standing allergic rhinitis

Low intensity statin

•Simvastatin 10 mg •Pravastatin 10-20 mg •Fluvastatin 20-40 mg

Chronic PAD treatment

•Smoking cessation •Control and treat comorbid diseases •Exercise program: develop collateral circulation •Antiplatelet - ASPIRIN, Pentoxifylline, cilostazol •Trial of phosphodiesterase inhibitors •Invasive interventions - angioplasty, stenting, bypass grafting

Conductive hearing loss

•Sound does not transmit well through EAC, TM, or ossicles -Obstruction -Effusion -Otosclerosis -Ossicular disruption •Often correctable

Perforation of TM: Refer

•Spontaneous resolution or possible tympanoplasty •Audiogram to determine if there is damage to ossicular chain

Pharyngitis/Tonsillitis: Etiology

•Spread by person-to-person contact via droplets of oral, respiratory and nasal secretions •Viral - most common -Rhinovirus, adenovirus, coxsackie, herpes simplex, Epstein-Barr, cytomegalovirus •Bacterial -Group A beta-hemolytic strep, N. gonorrhoeae, Corynebacterium diphtheriae, H. influenzae, M. catarrhalis

Lab testing in CAP

•Sputum gram stain and culture; Blood cultures; urine for pneumococcal antigen in adults with CAP is NOT routinely in adults with CAP managed in the outpatient setting -In pandemic conditions, testing for pathogen is prudent -Multiplex PCR panels - interpret with caution •Urinary antigen test for Legionella may be considered where indicated by epidemiological factors, such as association with a Legionella outbreak or recent travel •Procalcitonin serum levels -Is Released in response to bacterial toxin and inhibited by viral infections -Recommend that empiric antibiotic therapy should be initiated in adults with clinically suspected and radiographically confirmed CAP regardless of initial serum procalcitonin level (strong recommendation, moderate quality of evidence).

Pharyngitis/Tonsillitis: Education and Follow-up

•Strep Pharyngitis typically lasts 5-7 days with fever peaking at day 2-3 -May return to school/work after 24 hours fever free •Complete full course of antibiotic •Discard toothbrush to prevent reinfection

Typical bacteria in CAP

•Streptococcus pneumoniae - most common bacteria but declining due to vaccine •Haemophilus influenzae - Most common in tobacco users •Moraxella catarrhalis •Staphylococcus aureus -While rare, community-acquired MRSA infections tend to occur in younger healthy persons. -Risk factors: history of MRSA skin lesions, participation in contact sports, injection drug use, crowded living conditions, and men who have sex with men. •Aerobic gram-negative bacteria (such as Klebsiella or Escherichia coli)

Statin-associated muscle symptoms (SAMS) more likely to be statin related if:

•Subjective myalgia is bilateral •Involves proximal muscles •Has onset within weeks to months after statin initiations •Resolves after discontinuation of statins

Angle-closure/acute or narrow-angle glaucoma

•Sudden narrowing or closure of the anterior chamber angle results in inadequate aqueous humor drainage leading to elevated IOP and damage to the optic nerve

Red flags: Pneumothorax or PE

•Sudden onset chest pain •Hypotension, Syncope, Dyspnea, Tachypnea, Tachycardia •Recent surgery or immobility; oral contraceptive use

Red flags: Aortic dissection

•Sudden onset of knife-life /tearing pain in chest or upper abdomen •Possible radiation to the back •History of hypertension and/or smoking •Males smokers are at higher risk

Epiglottitis: Presentation

•Sudden onset of severe pain with swallowing or unable to swallow •Muffled "hot potato" voice •Toxic appearance •Classic posturing: sitting up, leaning forward, tongue hanging out, often holding cup to spit saliva •Fever •Lymphadenopathy •Minimal cough

varicose veins

•Superficial dilated tortuous veins arising from incompetent valves and high venous pressure in the lower extremities •Contributing factors: prolonged standing, heavy lifting, pregnancy, obesity •Greater saphenous vein and tributaries most commonly involved •Often progressive as incompetent valves increase pressure and distention in the next lower valve.

Cerumen Impaction: when to refer

•Suspected TM perforation •Tympanostomy tubes •Coexisting problems of ear such as severe infection •Unexplained hearing loss •Hearing loss not clearing with tx of impaction

Mono: treatment

•Symptomatic - rest, fluids •No contact sports, heavy lifting, strenuous activity for 2-3 weeks or duration of splenomegaly •Acetaminophen or ibuprofen and saltwater gargles •Avoid ampicillin or amoxicillin for GABHS due to potential for rash

Referral to Ophthalmologist for Conjunctivitis IF

•Symptoms worsen within 24 hours •Suspected herpes or gonococcal etiology •Reduction of visual acuity -infectious keratitis, iritis, angle-closure glaucoma •Ciliary flush - injection pronounced in a ring at the transition zone between the cornea and the sclera -infectious keratitis, iritis, and angle-closure glaucoma •Photophobia -infectious keratitis, iritis or corneal abrasion •Severe foreign body sensation that prevents the patient from keeping the eye open -infectious keratitis •Corneal opacity -infectious keratitis •Fixed pupil -angle-closure glaucoma •Severe headache with nausea -angle-closure glaucoma

AOM: Exam

•TM: bulging or retraction with displaced light reflex; may be opaque or erythematous; reduced TM mobility •Mastoid tenderness •Fluid in external auditory canal may indicate TM perforation

Aortic Aneurysm Dissection

•Tearing Pain, abrupt onset •Location: lower abdomen, flank, or back •Tender pulsatile abdominal mass •Hypo or Hypertension •Discrepancy in B/P readings between arms •Labs: decreased HCT, increased creatinine •Diagnostics: KUB shows aneurysm wall calcification, get CT with IV contrast if possible •Immediate Emergency Referral

Iritis - Anterior Uveitis: PE

•Tender to palpation •Opacities or haziness on cornea •Constricted pupil •Nodules on the iris •Hypopyon - an accumulation of white blood cells in the anterior chamber of the eye •Macular changes - lesions, edema •Frequently unilateral

Pharmacologic therapy for ALLERGIC conjunctivitis

•Topical antihistamine/vasoconstrictor combination, antihistamines with mast cell-stabilizing properties, mast cell stabilizers •For refractory symptoms, topical glucocorticoids •Refrigerated artificial tears to dilute and remove allergens

HSV Stomatitis: Treatment

•Topical treatments decrease shedding •Started before vesicle rupture may shorten course and reduce postherpetic pain -Acyclovir200-800mg 5 times/d x 7-14 days -Valacyclovir 1000 mg BID x 7-10 days •For suppression therapy -Acyclovir 400 mg BID every day

Mono: etiology

•Transmission is commonly oropharyngeal •Respiratory tract viral shedding can occur for months after infection •Incubation is 30-50 days

Corneal abrasion: Etiology

•Trauma -Fingernails, paws, paper or cardboard, branches, etc. •Foreign body -Rust, wood, glass, plastic, fiberglass •Contact lens related -Removal of over-worn, improperly fitting or improperly cleaned contact lens

Iritis (anterior uveitis): Etiology

•Trauma, idiopathic ankylosing spondylitis, reactive or psoriatic arthritis, inflammatory bowel disease •Less common - herpes, syphilis, TB

Uveitis: Etiology

•Trauma, infections, inflammation or neoplasms •Isolated eye disease •Masquerade syndromes (ocular lymphoma, leukemia, retinoblastoma) •Idiopathic (~25%)

Oral Candidiasis: management

•Treat underlying cause •Probiotics lactobacillus and Bifidobacterium may be beneficial •Dentures wearers -Nystatin ointment 100,000 units/gram on fitting surfaces of dentures and corners of mouth for 3 weeks -Remove dentures at night; clean twice weakly with diluted (1:20) bleach or soaking solution containing benzoic acid or chlorhexidine gluconate •Clotrimazole troches 10 mg (suck on for 20 min) 5x/day for 7-14 days •Nystatin pastilles 200,000 U QID for 7-14 days •Moderate/severe dz: Fluconazole 100-200 mg QD x 7-14 days

Gingivostomatitis: Etiology - Adults

•Trench mouth/Vincent stomatitis - infection likely stress mediated •Aphthous ulcers (canker sores) •Stress, systemic disease, medications, oral trauma •Herpes simplex "cold sores" - HSV 1 and HSV 2 •Smoking •Food hypersensitivity - citrus, nuts, coffee, chocolate, potatoes, cheese, figs, gluten •Allergic or toxic drug reactions •Malnutrition or Nutritional deficiencies: B6, B12, folic acid, vitamin C, iron

Non-allergic asthma triggers

•URIs, rhinitis, sinusitis, post nasal drip •Exercise •GERD •Smoke and pollutants •Weather changes •Stress •Hormonal changes •Medications--Including Aspirin, NSAIDs, indomethacin, Beta blockers

Blepharitis: Symptoms

•Unilateral or bilateral eye irritation, itching, erythema of the lids or changes in eyelashes •Eye burning, watering, gritty sensation, crusting and matting of the lashes and medial canthus, red eyelids, red eyes, photophobia •Symptoms usually worse on waking •Purulent drainage if infection has developed (conjunctivitis/stye) •History of recurrent stye, acne, rosacea or eczema

Survival in hypoxemic patients is proportionate to the # of hrs/d O2 is used--->

•Usually 1-3 L/min at least 15 hours per day •Has beneficial impact on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics, and mental state

Glaucoma: PE

•Visual acuity •Peripheral vision by confrontation •Inspect outer eye and sclera •Pupillary response •Funduscopic exam to assess optic cup-to-disc ratio Open Angle •Often incidental finding during ophthalmic exam •Normal or increased (>20 mm) IOP •Increased cup to disc ration •Normal pupil Angle-Closure •Elevated (40-80mm) IOP •Corneal and lid edema •Conjunctival hyperemia •Ciliary flush •Fixed, mid-dilated pupil •Pain with eye movement •Shallow anterior chamber

COPD Physical Assessment

•Vital signs RR- tachypnea, HR- tachycardia, low O2 saturation •HEENT pursed lip breathing, pallor, peri-oral cyanosis •Respiratory AP diameter changes, retractions, accessory muscle use, wheezes •CV -Signs that dyspnea may be cardiac rather than pulmonary related -Right sided heart failure more likely related to COPD than left •Abdomen Hepatomegaly (cor-pulmonale) •Extremities Peripheral edema, cyanosis, clubbing •Neuro Somnolence or confusion

Blepharitis: Tx

•Warm moist compress 15 min QID followed by gentle lid massage •Daily lid hygiene using dilute tear-free shampoo with warm, damp cotton ball •NO use of contacts or eye make-up while symptomatic •Topical ophthalmic antibiotics -Bacitracin, sodium sulfacetamide, erythromycin, ofloxacin, 1-4 times day for 1-2 wks

In bacterial rhinosinusitis, symptoms typically improve within 2 weeks without antibiotics. Practice--->

•Watchful waiting •Deferring antibiotic treatment for up to 7 days after diagnosis and limiting management to symptomatic relief BUT, Consider immune status, coexisting bacterial illness, age, general health, cardiopulmonary status, comorbid conditions

Oral candidiasis: Assessment findings

•White raised patches in the mouth •RUBS OFF easily leaving underlying red, raw surface

Moderate intensity statin in ages 40-75

•With DM and LDL-C ≥ 70 mg/dL •Without DM but borderline -intermediate ASCVD risk with risk enhancing factors for primary prevention

BP treatment in black adults

•With HTN but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. •Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg

BP treatment during Pregnancy

•Women who are planning to OR become pregnant should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy for treatment of HTN. •ACE-I, ARBs, or renin inhibitors are CONTRAINDICATED!

During severe asthma attack

•wheezing may be absent due to very limited airflow - will see globally ↓ breath sounds, prolonged expiration •Pulsus paradoxus (> 12 mm Hg fall in BP during inspiration)

Initial BP meds in Chronic Kidney Disease

•≥ stage 3 or stage 1 or 2 with albuminuria [≥300 mg/d), treat with an ACE inhibitor (or ARB if not tolerated) to slow kidney disease progression

Recurrent rhinosinusitis

≥ 4 annual episodes with no symptoms in between

Acute Bronchitis: Physical Exam

●Afebrile or temp < 101 ●Purulent nasal secretions, post nasal drainage, sinus tenderness ●Cervical lymphadenopathy ●Respiratory wheezes or rhonchi (may clear with cough) ●Tachycardia ●No lung consolidation symptoms

TB monitoring and follow up

●Before initiation of therapy -Baseline serum bilirubin, hepatic enzymes, BUN/creatinine, CBC/platelets before starting drug therapy -Assess visual acuity and red/green color vision (ethambutol) -Uric acid (pyrazinamide) -Audiometry (streptomycin) -Ongoing labs for suspected liver disease or abnormal initial results ●Sputum smear/culture -Monthly until converting to negative -After 2 negative cultures, perform additional culture at end of treatment -If cultures remain (+) after 3 months of treatment, assess for nonadherence and drug-resistant organisms. -Consider Directly observed therapy (DOT) and addition of two drugs

TB signs and symptoms

●Chronic Cough (Dry, progresses to purulent sputum) ●Night Sweats ●Unexplained weight loss -Blood streaked sputum -Looks chronically ill and malnourished -Anorexia -Fever - Chills -Malaise -Possible rales, likely normal chest exam -Extrapulmonary sx: lymphadenitis, miliary disease -Can be asymptomatic- assess for risk factors

Acute Bronchitis: follow up

●F/U if no improvement or symptoms worsen after 72 hrs ●Typically recovery in 7-14 days ●Cough may last several weeks ●Symptoms and duration may be worse in smokers ●Monitor for complication such as pneumonia ●Refer to pulmonologist if no improvement in 4-6 weeks or having more severe symptoms

TB risk factors

●HIV infection ●Close contacts of patients with newly diagnosed TB ●Homeless, immigrants, travel to endemic area ●Living in over crowded or substandard housing ●Institutionalized individuals and prison guards ●Health care workers ●Patients with malignancy, malnutrition

Acute bronchitis symptoms

●Initially dry cough, then productive cough worse at night with mucopurulent sputum ●Afebrile or low grade temp, malaise, fatigue, headache, chest burning, substernal pain, occasional dyspnea, wheezing

Acute Bronchitis: Patho

●Mucous membranes of airways become inflamed and edematous with increased bronchial secretions. ●Bronchial epithelium is damaged and muco-ciliary function impaired

When CXR is normal with persistent cough, most likely causes are:

●Postnasal drip ●Asthma ●GERD •Acute cough has lasted 3-8 weeks following acute respiratory infection: ●Consider post-infectious cough or pertussis

Active TB treatment

●REFER ●Educational and counseling -Adherence to treatment -Potential for transmission -Nutrition and general hygiene ●Medication -6 or 9 month multi-drug regimen with Rifampin, Isoniazid, Pyrazinamide, Ethambutol (RIPE) ●Patients with concomitant HIV disease is more complex ●Pyrazinamide is avoided in pregnancy ●Side effects with Isoniazid (INH): peripheral neuropathy (give pyridoxine - vit B 6), hepatotoxicity

Acute bronchitis: treatment

●Rest, hydration, humidification, smoking cessation ●Antibiotics not generally indicated as most cases are viral EXCEPTIONS- Secondary bacterial infections or Adults w/COPD Amoxicillin, Bactrim, clarithromycin, azithromycin ●Consider antivirals if influenza ●Avoid antihistamines - dry out secretions ●Decongestants if sinus component ●Antipyretic/Analgesic - costrochondral pain/fever ●Cough suppressants -at night, if cough disturbs sleep ●Inhaled beta agonist for cough with bronchospasm

Acute Bronchitis: Etiology

●Viruses most common (95%) rhinovirus, coronavirus, adenovirus, influenza ●Bacterial Bordetella pertussis - 2nd leading cause Streptococcus pneumonia/ Haemophilus influenzae are more common in smokers and patients with COPD

Long term controller meds in asthma: Combination Medications (ICS/LABA)

◦Budesonide/Formoterol (Symbicort) ◦Mometasone/Formoterol (Dulera) ◦Fluticasone/Salmeterol (Advair)

The peak flow meter can be used to

◦Discover triggers for asthma symptoms ◦Recognize early changes such as airway tightening before symptoms occur ◦Decide if an asthma action plan is working or if medical attention is needed ◦Determine whether asthma medications need to be added or adjusted ◦Know when to seek emergency care

Monitoring asthma control: Fractional Exhaled Nitric Oxide Testing

◦FeNO testing should not be used in isolation to assess asthma control, predict a future asthma exacerbation, or assess the severity of an exacerbation. •may be used in conjunction with an individual's history, clinical findings, and spirometry as part of an ongoing asthma monitoring/management strategy • FeNO levels are affected by comorbid conditions, including allergic rhinitis and atopy, or behaviors such as smoking. • Cutpoints for adjusting therapy to reduce the risk of exacerbation have not been established.

Moderate to severe persistent asthma

◦ICS-formoterol in a single inhaler used as both daily controller and reliever therapy (SMART)

Long term controlled meds in asthma: Mast cell stabilizers

◦Inhibit asthmatic response to allergens and exercise-induced bronchospasm ◦Effective when taken before exposure/exercise◦Less predictable response than with ICS ◦Cromolyn (Intal) - MDI or Nebulizer ◦Nedocromil (Tilade) - MDI

Long term controlled meds in asthma: Leukotriene modifiers

◦Montelukast (Singulair) ◦Zafirlukast (Accolate) - Leukotriene receptor antagonists ◦Zileuton (Zyflo) - Decreases leukotriene production

Determine personal best PEF

◦The highest peak flow number obtained over a 2- to 3-week period when asthma is under good control.

To determine personal best PEF, take peak flow readings:

◦Twice a day for 2-3 weeks when asthma is in good control ◦At the same time in the morning and in the early evening ◦Before taking a short-acting beta-2 agonist for quick relief ◦Continue to take peak flow readings each morning.

During asthma attack, may not be able to obtain lung function measures (FEV1 or PEF) initially, but measure after one hr of treatment may be helpful in determining further treatment

◦≥ 80% of predicted or personal best is good ◦50-79% of predicted or personal best- continue SABA/oral steroids ◦< 50% of predicted or personal best- need urgent care