PROVIDER 01
PMH: Hx Hep A infx: do I need vaccine?
vaccine or Immune globulin are only effective if given within the *first 2 weeks after exposure.*
Measles Exanthem characteristic
rash is erythematous, maculopapular, blanching rash classically begins on the face and spreads cephalocaudally and centrifugally. In later stages rash become nonblanching It may or may not be itchy
Vanco most importance AE
red man syndrome
Raynaud Phenomenon common triggers (5)
stress cold temp nicotine caffeine med that affects sympathetic nervous system (pseudoephedrine)
candidiasis topical local site is tx'ed w/
topical
CN V is...
trigeminal nerve
Gestational Diabetes Mellitus glucose goal:
1 hr post pran <140 mg/dL 2 hr PP < 120 Fasting: 65-95
We diagnose RP if the patient has a positive response to all three of the following questions...
1. Are your fingers unusually sensitive to cold? 2. Do your fingers change color when they are exposed to cold temperatures? 3. Do your fingers turn white, blue, or both?
Grave's
hyperthyroidism
skene's gland function
lubricate's urethra opening Increased blood flow to the genitalia during arousal activates the Skene's glands to produce a milky-white secretion, which includes enzymes resembling that of male prostate fluid
Diphtheria tx:
macrolide (erythromycin)
metformin vs pcos
metformin helps PCOS -*also helps w/ pregnancy in diabetic pts as well
txing suspected bacterial sinusitis w/ what abx for how long?
mild to moderate: Augmentin 500 mg/125 mg PO TID or 875 mg/125mg PO BID 5-7 days severe: Augmentin high dose 2000mg/125 mg ER PO BID 7-10 days
Cataplexy s/s
muscle weakness usually only affects head and neck severe episodes can cause total body weakness
diphtheria reportable?
must be reported to health department and CDC
Meglitinide vs food
must be taken at start of the meal
*Lyme Disease Preventative Tx*
within 72 hrs of tick removal, Doxy 200 mg single dose
Obstructive Sleep Apnea patho
not completely understood, is likely due to the interaction between unfavorable anatomic upper airway susceptibility and sleep-related changes in UA function
Theophylline moa
"PHILLING your lugns!" inhibits Phosphodiesterase (PDE) so more cAMP! bronchodilation! careful with INHIBITORS of CYP450
beta blocker withdrawal
"rebound" effect characterized by tachycardia and HTN. Pts w/ ischemic heart disease may have exacerbation of angina or acute ischemic events.
fundal height is equal to...
# of weeks of gestation +/- 2 cm *between 20 and 35 wks
pediarix eligible age group
6 weeks through 6 years of age.
blunt neck injury to neck: initial evaluation
ABC and C-Spine immobilization
Palmar grasp reflex disappears by
6 mths of age
Aphthous Stomatitis duration
7-14 days
# of diapers: 5-9 mth baby
8 diapers
INR normal range
<1.1
HTN first line for diabetics
ACEi (or ARB)
Kaposi sarcoma is sign of
AIDS
canker sores aka
Aphthous stomatitis
Pentacel covers
DTaP + IPV + HiB
Urticaria aka
Hives
Adderall is schedule
II
methimazole moa
Inhibits thyroid peroxidase
Yaz is approved to tx
PMDD Acne Pregnancy
Azo aka
Phenazopyridine HCl
Finasteride brand name
Proscar
OCD class(es) of med used
SSRI
Cimetidine brand name
Tagamet
Diazepam brand
Valium
Degludec brand
Tresiba
Red man syndrome tx
antihistamine
h pylori dx
carbon urea breath test stool antigen test blood antibody test
luteal phase of menstrual cycle happens during
day 15-28
Opposite of Graves
hypothyroidism
hcg doubles q
q 72 hrs
rotavirus treatment
rehydration
crossed eyes AKA
strabismus
bartholin's gland function
vaginal lubrication during sexual arousal
underweight BMI pregnant mom: recommended range of total wt gain
28-40 lbs
tdap vaccine - proper capitalization - has reduced concentration of what antigens
- Tdap - Diphtheria and Pertussis antigens
epididymitis dx
-cremasteric reflex will be present (vs it absence in testicular torsion) -U/A is a MUST -C/S & Gram Stain is a MUST -dx can be made clinically; however, if dx is uncertain, Doppler US or nuclear scan may be helpful, revealing increased blood flow to the affected epididymis
Selection of LABA vs LAMA for COPD management
*Both LAMAs and LABAs reduce exacerbations, but LAMAs have a greater effect. Otherwise, no significant difference noted between efficacy (in terms of quality of life or dyspnea) Individual pts may prefer one bronchodilator over the other - e.g. some pts experience resting tachycardia w/ LABA therapy and therefore prefer a LAMA - e.g. some prefer LABA over LAMA b/c of dry mouth or urinary retention that can be bothersome
FODMAP abbreviation
*F* Fermentable *O* Oligosaccharides : Fructose & Galactose *D* Disaccharides : Lactose *M* Monosaccharides : Fructose *A* And *P* Polyols : Sugar Alcohols : Mannitol, Sorbitol, Xylitol
Parkinson's Disease Workup
*No diagnostic studies indicated 2 of 3 cardinal manifestations - bradykinesia PLUS tremor or rigidity CT or MRI Urinalysis to rule out UTI
Chlamydia dx
*Nucleic Acid Amplification tests* NAATs (recommended for *non symptomatic clients*) - can be a urine or swab
digoxin has what kind of efx on heart
+ inotropic - chronotropic - dromotropic
Metronidazole AE
- GI upset, less when take w/ food - metallic taste in the mouth - transient leukopenia, thrombocytopenia
Muscarinic medications always end in...
-ium (e.g. Ipratropium; except for Glycopyrrolate)
Tdap vaccine schedule
1 dose 11-12 y/o, then booster (Td) q 10 yrs
Myasthenia gravis treatment
1. Acetycholinesterase inhibitor - Pyridostigmine 60 mg and 180 mg SR - Neostigmine methylsulfate (Prostigmin) 0.25 to 0.5 mg 2. chronic immunosuppressive therapy - glucocorticoid 3. immunomodulatory therapies (rapid result) - IVIG -plasma exchange 4. thyrodectomy *Pt w/ severe disease, or rapidly worsening disease, should be tx'ed much like those in myasthenic crisis using rapid therapies (plasma exchange or IVIG followed by glucocorticoids and other immunosuppresive therapies)
ADHD screening tools for adults
1. Adult ADHD self report scale 2. ADHD rating scale IV 3. adult ADHD clinical iagnostic scale 4. brown attention-deficit disorder symptom assessment scale for adults
Tic disorder types
1. Tourette's 2. Persistent Motor or Vocal Tic Disorder 3. Provisional Tic Disorder
Interstitial Cystitis risk factors
1. UTI 2. Prostatitis 3. Posthysterectomy or other pelvic surgery 4. Meds: CCB, cardiac glycoside (Digoxin) 5. hypersensitivity conditions - fibromyalgia - IBS - chronic headaches - vulvodynia - Sjogren syndrome
what ages are well child check ups
1. 1st week (3-5 days) 2. 1 mth 3. 2 mth 4. 4 mths 5. 6 mths 6. 9 mths 7. 12 mth 8. 15 mths 9. 18 mths 10. 2 yrs 11. 2 1/2 yrs 12. 3 yrs and annual to 21 y/o
Developmental Milestones 2 mths
1. 50-90% able to smile spontaneously; more than 90% will smile responsively 2. turns head toward sounds 3. coos, makes gurgling sound 4. pays attention to faces 5. hold head up and begins to push up when lying on tummy 6. begins to act bored if activity doesn't change
Provisional Tic Disorder
1. >= 1 motor &/or >= 1 vocal 2. persists < 1 yr 3. started before age 18
Persistent Motor or Vocal Tic Disorder criteria
1. >= 1 motor OR >= 1 vocal tic (but not both) 2. persists >= 1 yr 3. started before age 18
Tourette's Disorder criteria (3)
1. >= 2 motor & >= 1 vocal tic 2. persists >= 1 yr 3. started before age 18 (often appears in 4-6 )
SGLT2 inhibitor SE
1. osmotic diuresis (increased urination) 2. hypotension (potential for volume depletion) 3. hypoglycemia (esp when used w/ insulin or secretagogue) 4. hyperkalemia (increased CRE and decreased eGFR) 5. AKI 6. UTI / genital yeast infx (d/t sugar; are more common among pts taking this medication) 7. *bone fractures (as early as 12 wks after initiating the drug) 8. Atypical Ketoacidosis
Rheumatoid Arthritis ddx
1. osteoarthritis 2. viral arthritis 3. systemic rheumatic diseases 4. SLE 5. psoriatic arthritis 6. seronegative spondyloarthropathies 7. fibromyalgia 8. tendinitis 9. bursitis 10. other viral infxs s
Vitamin B12 occurs mostly in what pts...
1. pernicious anemia 2. hx gastrectomy 3. diseases a/w malabsorption 4. long term vegans and vegetarians
Endometrial Cancer risk factors
1. Unopposed estrogen 2. Obesity- having more fat tissue can increase the endometrial cancer risk (more fat may increase estrogen lvl) 3. Nulliparity or Infertility- during pregnancy, the hormonal balance shifts toward more progesterone. Therefore having many pregnancies reduces endometrial cancer risk, and nulliparity increases risk 4. Late menopause (more estrogen exposure) 5. Chronic anovulation- Polycystic ovaries and some ovarian tumors such as granulosa-theca cell tumors cause an increase in estrogen relative to progestin 6. Tamoxifen use- antiestrogen drug that acts like an estrogen in the uterus increases risk 7. Family Hx 8. Diet- diet high in animal fat
huntington disease movement problems, other s/s, and clinical progression
1. chorea- purposeless, dance-like movement 2. athetosis- slow "snake-like" 3. abnormal eye movements 4. poor coordination - can't suppress movement problems - STOPS W/ SLEEP -progressive loss of voluntary control is a characteristic feature of HD -abnormal eye movements can be a prominent finding in HD, particularly in younger adult pts chorea, psychiatric illness, and dementia begin insidiously w/ movement abnormalities and/or w/ psychiatric and cognitive features. wt loss and cachexia common despite efforts to maintain appropriate caloric intake -pathophysiology of weight loss is not well-understood -possible contributors include energy expenditure due to hyperkineticmovements and altered cellular metabolism in muscle or adipose tissue Clinical Progression: -Early stages: pts are generally functional and independent w/ most ADL, often remaining independent and able to work and drive. Symptoms of HD are present, such as slight involuntary movements, mild incoordination, difficulty w/ complex mental tasks, some degree of irritability, disinhibition, or depression. slowed voluntary eye movements can be seen, particularly in younger individuals -Middle stage: begin to lose ability to work, drive or manage their own affairs w/o assistance. In most cases, they will require some assistance with eating, dressing, and personal care. Cognitive decline worsens with diminished ability to solve problems. There is usually increased chorea and difficulty with voluntary motor movements. Impairments in walking and balance may lead to falls. Other problems may include swallowing dysfunction and weight loss. -Late stage — The slow but relentless deterioration in cognitive and motor function causes significant morbidity and early mortality. Patients in the late stage of HD require round-the-clock supervision and care in all activities of daily living [60,61]. The loss of voluntary motor control worsens; the few remaining voluntary movements are often ballistic and high-amplitude, which may cause injury due to falls or limb trauma. Most become bedridden. Dysphagia may require placement of a feeding tube to maintain adequate nutrition. Although often nonverbal, patients in the late stage of HD may retain some comprehension. -While sharing the need for 24-hour care, patients with late stage HD can differ dramatically in disease expression [61]. As examples, some have prominent, severe behavioral disturbances, some have severe chorea and gait disturbance without significant behavioral involvement, and others have severe unawareness of symptoms. -The advance stage of HD can last for a decade or longer, depending on the level of care [61]. Complications of immobility, such as aspiration pneumonia and other infections, result in death 10 to 40 years after disease onset [62].
Interstitial Cystitis subjective hx
1. persistent urge to void 2. pain w/ bladder filling, relieved by emptying 3. increased urinary frequency 4. nocturia (going pee more than once a night 5. increase in symptoms during menstruation 6. low back pain w/ bladder filling
Thiazolidinedione SE
1. increased risk of CV events (myocardial infarction, stroke) 2. fluid retention / edema (exacerbates symptoms a/w heart failure) 3. wt gain 4. risk of osteopenia and fractures 5. risk of hepatitis and liver failure (monitor liver enzymes, esp. first few mths)
UTI risk factors
1. pregnancy 2. DM 3. diaphragm use (IUD is NOT a risk factor) 4. new sexual partner 5. not voiding before and after sex 6. female 7. increasing age 8. frequent bubble baths
Melasma most common triggers:
1. pregnancy 36% 2. intense sun exposure 27% 3. contraceptive pills 16%
Stasis dermatitis tx
1. pressure stocking or wraps can be used 2. elevate the leg at heart level once every 2 hrs for 15 mins and while you sleep 3. TOP steroid helps w/ inflammation and itch
Trichomoniasis complication
1. preterm labor 2. cervical cancer 3. prostate cancer
TZD AE's
1. wt gain 2. edema 3. can precipitate heart failure- contraindicated in HF 4. rosiglitazone a/w MI 5. may increase fracture risk in women 6. may increase ALT
Amphetamine Withdrawal s/s
1. Fatigue 2. Vivid bad dreams 3. Insomnia 4. Hypersomnia 5. increased appetite 6. psychomotor agitation 7. retardation
loop diuretic list
1. Furosemide (Lasix) BID 2. Bumetanide (Bumex)
Thiazide diuretic list
1. HCTZ 12.5 to 25 mg PO QD 2. Chlorthalidone 12.5 to 125 mg PO QD (best one) 3. Indapamide (Lozol) PO QD
poison ivy management:
1. Zanfel poison ivy wash (removes uroshiol oil from poison ivy) 2. OTC hydrocoritsone cream 1% BID
overweight BMI pregnant mom: recommended total wt gain
15-25 lbs
anterior fontanel closes by
12-18 months
Urinalysis: Specific Gravity
1.005-1.025
PT normal range
10-14 secs
Persistent Diarrhea length
2 < x < 4
Triazolam half life
2 hours
Pediarix schedule
2, 4, 6 mths
Pentacel schedule
2, 4, 6, 12-15 mths
IPV vaccine schedule
2, 4, 6-18 mths, 4-6 yrs
normal BMI pregnant mom: recommended range of total wt
25-35 lbs
TIBC normal range
250-450 mcg/dL
Scopolamine: duration of effectiveness
3 days
Moro reflex disappears by
3 mths of age
Bacterial Vaginosis: Amsel Criteria
3 of the following must be met: - vaginal pH >4.5 - presence of > 20% per HPF of clue cells on wet mount exam - positive amine or "whiff" test - homogeneous, non-viscous, milky-white discharge adherent to the vagnial walls
pregnant mom: limit tuna to how much?
4 medium cans a week ( or 2 tuna steaks a week)
USPSTF pap smear guidelines <cervical cancer, cervical dysplasia, HPV>
<21 y/o: not recommended < 30 y/o: q 3 yrs >= 30 y/o: q 3 yrs (q 5 yrs if w/ HPV testing)
infertility definition
<35 y/o -12 mths no pregnancy >=35 y/o - 6 mth no pregnancy
short acting beta 2 agonists
albuterol, levalbuterol
Gout prevention: Urate level goal
<6 mg/dL
chronic sinusitis lasts
> 3 mths
Chronic Diarrhea length
> 4 wks
Pernicious anemia is more often seen in what age group?
> 50 y/o
Carotid Artery Stenosis def
> 60% stenosis in carotid artery Moderate: - < 69% narrowing Severe: - 70- 99% narrowing
recurrent cystitis - def
>= 2 infx in 6 mths or >= 3 infx in 1 yr
abnormal hematuria is commonly defined as...
>= 3 RBC/hpf in a spun urine sediment
Vanderbilt rating scale is designed for what age
>= 4 years
Gonorrhea vs infants
Neonatal conjunctivis can happen
CHA2DS2-VASc score result
>=2 - recommend chronic anticoagulation male w/ score of 1, reviewers have differing approaches (age 65-74 is a stronger risk factor than the other features conferring a CHA2DS2-VASc score of 1 female w/ CHAD2 score of 0 or 1 in females, suggest no anticoagulant therapy; pts who are particularly stroke averse and who are at low bleeding risk may reasonably choose anticoagulation
Bilateral tubal ligation purpose
???
when to change therapy for depression
A change in tx should be considered for patients who have not improved after 4 to 12 wks of treatment. Once remission is achieved, tx should be continued at the same dose for at least 6 to 12 mths to prevent relapse. The decision of when to terminate treatment is based on the patient's risk of recurrence.
what causes menstrual bleed to begin
drop in progesterone
Parkinson's disease patho
A decreased number of neurons in the substantia nigra secrete dopamine (inhibitory neurotransmitter), leading to an imbalance between excitation and inhibition in the basal nuclei. the excess stimulation by Acetylcholine affects movement and posture by increasing muscle tone and activity.
UTI tx for pregnant people
Amoxicillin or Keflex
huntington average age of onset
40 y/o (depends on number of CAG repeats)
underweight BMI pregnant mom: 1st trimester total wt gain
5 lbs
Ottawa Knee Rules
A knee X-Ray series is only required for knee injury patients with any of these findings: 1. Age 55 or older -OR- 2. Isolated tenderness of the patella (No bone tenderness of knee other than patella) -OR- 3. Tenderness of the head of the fibula (doesn't have to be an isolated tenderness) -OR- 4. Can't flex to 90 degrees -OR- 5. Unable to bear weight both immediately and in the emergency room department for 4 steps (Unable to transfer weight twice onto each lower limb regardless of limping) Tips: -Tenderness of patella is significant only if an isolated finding -Use only for injuries < 7 days -"Bearing weight" counts even if the patient limps
Minoxidil MOA
A potassium channel opener, causing hyperpolarization of cell membranes. Theoretically, by widening blood vessels and opening potassium channels, it allows more oxygen, blood, and nutrients to the follicles.
glucagon
A protein hormone secreted by pancreatic endocrine cells that raises blood glucose levels; an antagonistic hormone to insulin. releases glucose from the liver
Flu A vs B vs C vs D
A: found in many species including humans, birds, and pigs; capable of causing pandemics; accounts for 75% of confirmed seasonal influenza infx overall; Some influenza A subtypes can cause more severe disease than others; In the past, it was thought that infection with influenza A was more severe than infection with influenza B. However, a 2015 study in adults with influenza A and influenza B found they both resulted in similar rates of illness and death. B: typically only found in humans C: typically only found in humans, causes mild flu; also known to occur in dogs and pigs
Metabolic Syndrome diagnosis
ATP III: at least 3 of the following conditions must be present - HTN - abdominal obesity (greater than 40 inches in men or greater than 35 inches in women; waist to hip ratio of 1.0 or higher in men or 0.8 in women - Hyperlipidemia: increased triglycerides greater than 150 mg/dl; decreased HDL less than 40 mg/dl - fasting plasma glucose greater than 100 mg/dl as a result of hyperinsulinemia and peripheral insulin resistance. Pt w/ metabolic syndrome are at greater risk of T2DM and CV disease
FODMAP foods
AVOID ENTIRELY IF POSSIBLE - Garlic and onions Many vegetables, fruits (contains high fructose), meats, dairy, cereals, grains, breads, biscuits, pasta, nuts, etc
Abdominal X-ray aka
AXR KUB
bartholin gland cyst prevalence
About 2 out of 10 women can expect to get a Bartholin's gland cyst at some point. It typically happens in your 20s. They're less likely to develop as you age.
croup s/s
Abrupt onset of a barking cough, inspiratory stridor, and hoarseness Initial: - nasal discharge, congestion, and coryza and progress over 12 to 48 hours to include fever, hoarseness, barking cough, and stridor. -As airway obstruction progresses, stridor develops, and there may be mild tachypnea w/ a prolonged inspiratory phase. Respiratory distress increases as upper airway obstruction becomes more severe. Rapid progression or signs of lower airway involvement suggests a more serious illness *minimal, if any, pharyngitis
MAOI - absolute contraindication food - food in moderation - meds to avoid
Absolute contraindication food: - cheese (other than cream cheese, cottage cheese) - caviar - liver - smoked/pickled/cured fish/meat - ripe avocados - canned figs - yeast extract - chianti red wine - beer - fava beans - many more in moderation can eat,... - chocolate - coffee meds to avoid: - cold meds - allergy meds - decongestatnts - cough meds - stimulants - meperidine - ssri - bupropion - mirtazapine - nefazodone - trazodone - venlafaxine
Chronic bronchitis vs abx
Abx only helpful in acute exacerbations of chronic bronchitis *common clinical practice: use Abx empirically in pts who demonstrate a fever or a change in sputum character (directed against Strep, Haemophilus, Moraxella catarrhalis)
altitude sickness prescription
Acetazolamide (Diamox) 125 mg PO q 12 hrs 1 day before ascent and continue for 1st 2 days at altitude or longer if still climbing
altitude sickness: Rx
Acetazolamide 125 mg q 12 hrs beginning the day before ascent and continuing the first 2 days at altitude or longer if ascent continues
Opposite of Cushing's
Addison's
ASQ-3 stands for...
Ages and Stages Questionnaire
PID Dx Criteria
Any of of 3: - Cervical Motional Tenderness ("Chandelier Sign") - Uterine tenderness - Adnexal Tenderness
widened pulse pressure may indicate
Aortic regurgitation aortic stiffening severe iron deficiency anemia hyperthyroidism
Depression monotherapy vs combo therapy
monotherapy preferred due to SE profile - more meds mean more SE
Type 2 Diabetes Diagnostic Criteria <fasting blood glucose>
Asymptomatic T2DM: - 2 A1C >= 6.5% (2nd one on a different day) - 2 FPG > 125 mg/dL (2nd one on a different day) - 2 two-hour plasma glucose >= 200 mg/dL w/ 75 g OGTT (2nd one on a different day) *If 2 different tests are available and are concordant for the dx DM, additional testing is unnecessary *If two different tests are discordant, the test that is diagnostic of diabetes should be repeated to confirm the diagnosis *If the diagnostic test is consistent with prediabetes, it should be repeated annually. Symptomatic T2DM: - s/s hyperglycemia (polydipsia, polyuria, polyphagia, wt loss, blurry vision) - random glucose value >=200 mg/dL
Hydroxyzine brand
Atarax, Vistaril
Carotid Artery Stenosis patho
Atherosclerosis: - W/ aging, artery wlals become thicker and less flexible Atheromas: - plaques (aka atheromas) can develop on the interior ARTERY wall - over time plaque builds up and reduces blood flow to brain - Arterial narrowing increases risk of thrombus formation and subsequent stroke risk
Lorazepam brand name
Ativan
animal bites abx of choice
Augmentin is the preferred agent -prophylactic schedule: 3-5 days w/ close f/u -infx'ed wound w/ superficial abscess who undergo drainage receive initial parenteral abx therapy until infx is resolving, followed by PO therapy to complete 5-14 days course (continue abx at least 1 to 2 days after s/s have resolved -superficial wound infx (in the absence of abscess) w/o systemic infx s/s may be managed w/ wound debridement and PO abx therapy for 5-14 days w/ close f/u
Macrolide vs pregnancy
Azithro and Erythro are Category B; Clarithro and telithro are category C
Infliximab pregnancy category
B - studies thus far have shown that it is not a/w an increased incidence of congenital birth defects.
plantar fasciitis risk factors
Before the onset of pain, they may had increase the amount or intensity of activity including but not limited to running or walking. they may have also started exercising on a different type of surface or may have recently changed footwear Overuse (running and other weight-bearing), Improper footwear, Anatomic anomalies, Functional factors, Poor muscle strength, Obesity Risk reduction measures-correct underlying risk factors
Primary/Secondary Syphilis: recommended regimen for adult
Benzathine PCN G 2.4 million Units IM in single dose
ADHD tx
Best effective tx is COMBO of pharm and behavioral therapy first line: - methylphenidate (ritalin) OR amphetamine (adderall) other first line: - hx SUD: atomoxetine (Strattera) - active SUD: tx SUD, stabilize acute phase, then tx ADHD - w/ depression: Bupropion - w/ GAD (General Anxiety Disorder) or other anxiety: stimulant + SSRI - contraindication to pharm: CBT - prefers CBT: CBT
Beta receptor vs Muscarinic receptor in lung
Beta receptor causes bronchodilation Muscarinic receptor causes bronchoconstriction
Long acting glucocorticoids
Betamethasone (36-72 hrs) Dexamethasone (36-72 hrs)
Hepatitis B Vaccine Schedule
Birth, 1-2 mths, 6-18 mths
Pepto Bismol active ingredient
Bismuth Subsalicylate
traveler's diarrhea prophylaxis
Bismuth subsalicylate (Pepto-Bismol) - two 262-mg tablets four times a day (taken with meals and in the evening) can prevent traveler's diarrhea - 65 percent protection rate - Bismuth subsalicylate can be taken for up to three weeks Bactrim DS 160 mg/800 mg daily, or Vibramycin 100 mg daily, has been found to provide even better results for up to three weeks
Pregnancy vs Bismuth Subsalicylate
Bismuth subsalicylate is contraindicated d/t its association w/ intrauterine growth problems and premature fetal ductus arteriosus.
RSV cause what lung conditions
Bronchiolitis
Bydureon vs Byetta
Bydureon is a once-weekly injection, whereas Byetta must be injected twice a day. Compared to Byetta, the once-weekly dose of Bydureon cuts down on the number of injections and may increase adherence to the medication—that is, sticking to the medication long-term. It's easy to use. Bydureon is used along with diet and exercise to help control blood sugar levels and aid in weight loss.
Corticosteroid pregnancy category
C - oral clefts in babies born to mothers who get steroids during the 1st trimester
antifungal vs pregnancy
CDC recommends using only TOP vaginal antifungal agents (including butoconazole, clotrimazole, miconazole, and the prescription medications terconazole [Terazol] and nystatin [Mycostatin]) in pregnancy
Multiple Sclerosis work up
CSF MRI CBC serum glucose
HFrEF approved BB's
Carvedilol (either long acting or short) - 3.125 mg BID - target: 25-50 mg BID Metoprolol XL (long acting) - 25-50 mg QD - target: 200 mg QD Bisoprolol *Uptitrate the dose weekly but mostly biweekly basis until to target dose *just be on one betablocker not multiple
Halos are a common issue associated with which eye problem?
Cataract
sulfonamide vs pregnancy/lactation
Category C/D, may interfere w/ folate acid metabolism; use only if necessary in pregnancy; is excreted in milk
Pregnancy vs BZD
Category D/X: fetal damage and is excreted in breast milk
Gonorrhea: recommended regimen
Ceftriaxone 250 mg IM once PLUS Azithromycin 1 gram PO once *alternative regimen if ceftriaxone is not aailable -Cefixime 400 mg PO once PLUS -Azithromycin 1 gram PO once
Sexual Assault: recommended regimen
Ceftriaxone 250 mg IM once PLUS Azithromycin 1 gram PO once PLUS Metronidazole 2 gram PO once (OR Tinidazole 2 gram PO once )
H. Pylori pharm tx:
Clarithromycin triple therapy - Clarithromycin, Amoxicillin, and a PPI if no PCN allergy -Clarithromycin, Metronidazole, and a PPI ( if no prior Metronidazole use) if any prior macrolide use or local clarithromyci resistance rates >=15% - Bismuth quadruple therapy (Bismuth, Metronidazole, Tetracycline, PPI)
New York Heart Association Functional Classification NYHA
Class I: no symptoms w/ ordinary activity Class II: slight limitation of physical activity. comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina Class III: marked limitation of physical activity, comfortable at rest, but less-than-ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Class IV: unable to carry out any physical activity w/o discomfort. S/s of cardiac insufficiency may be present even at rest
croup diagnostic
Clinical Dx Radiographic confirmation of acute laryngotracheitis is not required in the vast majority of children with croup. Radiographic evaluation of the chest and/or upper trachea is indicated if the diagnosis is in question.
Hidradenitis Suppurativa Diagnostics
Clinical Dx (based on the recognition of characteristic clinical manifestations) Culture if you suspect MRSA, otherwise unnecessary Skin biopsy if you suspect SCC Imaging unnecessary
Measles Dx
Clinical Inspection + Check rubeola IgM/IgG AB
Psoriasis Diagnostics
Clinical diagnosis based on hx and PE. Labs generally not needed, although KOH to rule out tinea helpful, especially in inverse psoriasis. skin biopsy if diagnosis unclear or pustular cases Consider x-rays if complaints of joint pain to evaluate for psoriatic arthritis. Nail cultures (fungal disease) Uric acid lvls (gouts)
Pheochromocytoma clinical presentation
Clinical presentation - Classic triad: episodic headache, sweating, tachycardia (most pts do not have the 3 classic symptoms) - 1/2 have paroxysmal HTN
actinic keratosis diagnosis
Clinical; Confirm with biopsy (if unsure)
Uncomplicated Candidiasis: OTC recommended regimens
Clotrimazole 1% cream 5 gram intravaginally daily for 7-14 days OR Clotrimazole 2 % cream 5 gram intravaginally daily for 3 days OR Miconazole 2% cream 5 gram intravaginally daily for 7 days OR Miconazole 4% cream 5 gram intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository, one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository, one suppository for 3 days OR Miconazole 1200 mg vaginal suppository, one suppository for 1 day OR Tioconazole 6.5% ointment 5 gram intravaginally in a single application
croup management
Corticosteroids (PO or parenteral) should be administered to patients with croup of any severity. Epinephrine should be administered to patients with moderate to severe croup. -suggest dexamethasone rather than other glucocorticoids . We prefer dexamethasone because it is the agent most extensively studied and is inexpensive, easy to administer, and has a longer duration of action compared with other agents. Dexamethasone is given at a dose of 0.6 mg/kg (maximum of 16 mg) by the least invasive route
short acting corticosteroids
Cortisone (8-12 hrs) Cortisol (Hydrocortisone) (8-12 hrs)
Herpangina cause
Coxsackie virus A 1 to 6, 8, 10, 22 -which are serotypes of enterovirus
Hand Foot Mouth Disease cause
Coxsackievirus A 16 and Enterovirus A 71 (most common) other Coxsackie viruses
Pediarix covers which vaccines?
DTaP IPV Hep B
pediarix covers
DTaP, IPV, HepB
osteoporosis diagnostic dx
DXA scan - T score <= -2.5
osteopenia diagnostic result
DXA scan - T score between -1 and -2.5
subacute thyroiditis aka
De Quervain's (viral)
Huntington Disease prognosis
Death occurs in 10-20 yrs from dx d/t aspiration pneumonia or suicide
prednisone brand
Deltasone, predniSONE, Rayos, etc
Hirschprung's Disease Dx:
Diagnosis is established by rectal biopsy. Absence of ganglia on suction biopsy confirms HD diagnosis
Pyloric stenosis dx
Diagnosis is made clinically and also by palpation of "olive-like" mass may be palpable in RUQ. -Imaging can confirm IHPS when olive or peristalsis wave cannot be detected. US is typically procedure of choice for pt w/ typical clinical s/s. Fluoroscopic upper gastrointestinal series may be preferred for pt w/ bilious vomiting or other features suggesting more distal obstruction.
Parkinson's Disease dx
Diagnosis is primarily clinical. Diagnosis of PD is supported by therapeutic response to dopaminergic therapy or presence of levodopa-induced dyskinesia Generally, bradykinesia plus either tremor or rigidity must be present in order to make the diagnosis of idiopathic PD. Gold standard for diagnosis is neuropathologic exam, which is done post mortem.
Huntington disease who should be tested?
Diagnostic genetic testing for HD is indicated for... - symptomatic adult patients w/ unequivocal motor signs of Hx - asymptomatic pts w/ a family hx of HD
Functional Constipation causes
Dietary Factors: - Low-fiber diet - decreased fluid intake Behavioral Factors: - Anxiety - Fear of painful stooling - Embarrassment *Longer the stool is held, harder it is to pass
Nondihydropyridine CCB list
Diltiazem Verapamil
Infectious Mononucleosis transmission
Direct contact with infected saliva
Rhinitis Medicamentosa Tx
Discontinue irritant, topical corticosteroids
cushing disease vs cushing syndrome
Disease: caused by a pituitary gland tumor that oversecretes the hormone ACTH, which overstimulates the adrenal glands' cortisol production Syndrome: s/s a/w excess cortisol in the body, regardless of the cause -more common than disease
Huntington Disease tx
Doesn't affect overall survival, limited to symptom management and optimizing quality of life -provide calm predictable environment (chorea may increase w/ anxiety and stress) -reduce risk of injuries (pad reclining chairs, bed padding, lower lvl of bed) -wt loss tx (difficulty swallowing) Pharm tx involves decreasing dopamine with Neuroleptics (dopamine receptor antagonist) and Tetrabenazine (depletes dopamine) -pharm management of chorea may improve chorea but worsen other aspects of HD, including parkinsonism, cognition, and mood -initial therapy: suggest tetrabenazine or deutetrabenazine for pts who have moderately severe chorea (may exacerbate depression) -2nd gen antipsychotic can be used as an initial therapy for pts who have both chorea and agitation or psychosis. Rigidity and bradykinesia in HD generally do not require tx Depression managed w/ SSRI or TCA (later more likely to cause AE) No effective therapy for dementia a/w HD
Trazodone SE
Drowsiness (24-40%) Dizziness (20-28%) Dry mouth (15-34 %) N/V (10-21%) Blurred vision (5-15%) Headache (10-33%) Priaprism (<1%) Constipation (7-8%) Edema (3-7%) Nasal congestion (3-6%) Decreased libido (1-2%)
characteristics of major noncardiac causes of chest pain: GERD duration and characteristics
Duration: 5- 60 mins Character: visceral, substernal, worse with recumbency, no radiation, relief with food, antacids
Kawasaki dx criteria, tests, tx
Dx criteria 4/5 CRASH + fever (>=5 days) - sometimes pts don't meet this strict criteria. Vasculitis in coronaries is a definitive sign that dx is kawasaki - if they don't meet all the criteria, they are considered as "incomplete kawasaki". for these pts, refer to clinical guideline whether to tx them or not tests: no specific tests available but they provide CLUES in the early period they will have... - anemic - WBC increase w/ left shift in the beginning - increased CRP / ESR - increased liver enzyme Microscopic UA- mononuclear WBC w/o evidence of bacteria plt ct goes up after few wks ECG- look at coronary arteries and heart muscles for inflammation Tx: - effective tx = correct dx - main tx: IVIG (calms down the immune system and reduce inflamamtion) - ASA - inhibits cyclooxygenase; prevents plt aggregation (we actually take the risk in children and monitor the conditions carefully for Reye syndrome0
Nitrofurantoin target
E. Coli and Staph saprophyticus
which beta blocker is approved for pediatric use
ER metoprolol is the only FDA approved beta blocker for pediatric HTN.
Mongolian spots are common in...
East Asian Native Americans Polynesians Latin Americans African Americans ***Rarely in Caucasians
Bloody diarrhea vs abx therapy
Empirical treatment should be avoided in patients presenting with bloody stools, because potential causes include Escherichia coli O157 or other strains producing Shiga-like toxin -empiric treatment of bloody diarrhea is not recommended in immunocompetent patients while waiting for test results unless (1) the patient is an infant younger than three months and a bacterial etiology is suspected, (2) the patient has a fever documented in a health care setting, abdominal pain, and bacillary dysentery presumably caused by Shigella infection, or (3) the patient has recently traveled internationally and has a body temperature of at least 101.3°F (38.5°C) or has signs of sepsis. -Patients with clinical features of sepsis and suspected enteric fever should be treated empirically with broad-spectrum antimicrobials after blood, stool, and urine culture collection. Therapy can be narrowed once test results are available -Antimicrobial therapy should be avoided in patients infected with STEC O157, Shiga toxin 2, or STEC of unknown genotype.
Tdap / DTaP vaccine Absolute Contraindications
Encephalopathy, as evidenced by... - Coma - Altered LoC - Seizures w/in 7 days of a previous vaccine Guillain-Barre Syndrome w/in 6 wks of previous vaccine (has been linked DTaP, Tdap, and Td vaccine)
erythromycin brand
Erythrocin
Sjogren Syndrome cause
Exact cause unknown - some genetic and environmental factor
Iron Deficiency Anemia pharm
Ferrous Sulfate 325 mg PO BID/TID x 6-8 wks (contains 65 elemental iron) - Outside of the United States, IV iron is becoming first line ahead of PO iron for its superiority in efficacy and toxicity. Patients with severe, severely symptomatic, or life-threatening anemia should be treated with transfusion because correction of iron deficiency anemia using iron replacement requires time for iron administration and incorporation into RBCs.
Erythema Infectiosum aka
Fifth disease
Uveitis vs Iritis clinical presentation
Iritis has more limbal flush Uveitis has flushing of more sclera
"Typical" antipsychotics refer to...
First-gen antipsychotics
Trich tx in pregnant pt
Flagyl 2 g PO ONCE (metronidazole gel can be messy)
muscle belly def
Fleshy central portion of muscle.
Hand Foot Mouth Disease clinical manifestations
Flu-like symptom along w/ oral pain -> rash breaks out in few days (small vesicles on an erythematous base on the hands, feet, inside mouth; typically starts w/ painful lesions in mouth, gingiva then spreads to hand/feet) other s/s: - sore throat - vomiting - associated/ rash (macular, maculopapular) (lasts 1-2 wks) - vesicular lesions located on the oral mucosa, hands, and feet *highly contagious
Candidiasis PO agent
Fluconazole 150 mg PO single dose
Most commonly used synthetic mineralocorticoid is...
Fludrocortisone
Antidepressant that are wt neutral or may even cause wt loss include...
Fluoxetine (Prozac) and Bupropion (Wellbutrin, Zyban)
25 hydroxyvitamin D lab frequency
Follow-up 25(OH)D measurements should be made approximately 3 to 4 months after initiating maintenance therapy to confirm that the target level has been achieved
how to d/c beta blocker
For beta blockers with shorter half-lives which require twice daily administration (eg, propranolol, short acting metoprolol, carvedilol), we have patients take their usual dose once daily for one week, then every other day for one week, then stop the medication For beta blockers with longer half-lives that are administered once daily (eg, atenolol, long acting metoprolol, nadolol), we have patient take one-half their usual dose once daily for one week, then one-half their usual dose every other day for a week, then stop the medication. However, beta blocker withdrawal can be accomplished in less time if necessary, usually by taking one-half the usual dose every other day for a week.
Pediatric Constipation work-up <constipation lab>
Functional constipation requires no work-up If organic causes suspicious... Labs: - *TSH, T, T3 (hypothyroidism)* - BUN/CRE (renal failure) - Ca+, K+ (electrolyte disorder) - CRP (inflammatory bowel disease) Imaging studies: - Abdominal X-ray or US (assess colon and rectosigmoid areas if bowel disease suspected) - Spinal X-ray or MRI to r/o other causes like spinal or neurological abnormalities - Colonic transit study <rare> (motility disorders)
Tetracycline AE's:
GI efx- N/V, colitis DAMAGE TO TEETH (staining) & BONES -do not give to children/pregnant women Nephrotoxicity Hepatotoxicity (worse in pregnancy) Q-T prolongation (in Azithromycin)
Lomotil inhibits what?
GI motility - it is a non-analgesic opioid that stops diarrhea in its tracks and is contraindicated w/ infectious diarrhea
Macrolide AE's:
GI: heart burn, nausea, anorexia, abdominal discomfort, diarrhea QT prolongation *erythromycin is taken with food d/t severe GI efx. newer Macrolide has fewer GI SE*
Aminoglycoside is potent against
GN bacteria (pseudomonas) *no GP activity
Diabetes blood pressure treatment route
GOAL: < 130/80 mmHg ACEi or ARB initially If initial BP > 150/100: dual therapy (ACEi or ARB + CCB, BB, TZD) if not at goal by 2-3 mths, add CCB, BB, or TZD if not at goal by another 2-3 mths, add another agent if not at goal by another 2-3 mths, add additional choices (a-blockers, central agents, vasodilators, aldosterone antagonist)
Simethicone brand
Gas-X, Gas-Ex, Gas Aide
cupping of optic nerve is caused by
Glaucoma
hypoglycemic used during gestational diabetes
Glynase (glyburide) - the only sulfonyulurea that does not cross placenta
Concussion grades
Grade 1: symptoms last <15 minutes; no loss of consciousness; altered mental status lasts < 5 mins Grade 2: symptoms last >15 minutes; no loss of consciousnes; altered mental status for 5-15 mins Grade 3: loss of consciousness, sometimes just for a few seconds, more confusion
diphtheria cause
Gram positive bacillus Corynebacterium diphtheria
Polycystic Kidney Disease s/s
HTN in 50% of pts flank pain (will become bilateral flank d/t progressive bilateral formation of renal cysts) hematuria, proteinuria, polyuria, and nocturnia UTI and calculi are common Ruptured cyst sxs (causes severe pain, abdominal swelling, polyuria, hematuria, fever; Simple kidney cysts rarely harm kidneys or impair their ability to function.) Mitral valve prolapse in up to 25% arterial aneurysm in circle of Willis in 10-15 % Focal renal cysts are typically detected in affected subjects before 30 y/o ; hundreds to thousnds of cysts are usually present in the kidneys of most pts in the fifth decade
Vit D analogue effx on psoriasis
Has been shown to exert anti-proliferative effects on keratinocytes Down-regulation of pro-inflammatory cytokines
Myasthenia Gravis classic triad, s/s
Has profound effect on extraocular muscles ptosis diplopia dysphagia s/s - wake up feeling fine, end of the day starts feeling weak, sometimes from repetitive movement - better the next morning after getting some sleep
CAD assessment
Hx - family hx, sudden death, CAD - tobacco, ETOH PE: - during anginal episode, may note increased HR, elevated BP - New heart sound parodoxically split due to delayed relation of the LV myocardium and delayed closure of the AV - S3 or S4 - mitral regurg murmur (holosystolic (pansystolic) murmur) 12-lead electrocardiography within 10 minutes of presentation Troponin at presentation and three to six hours after symptom onset. BP in legs, carotid imaging Stress test for risk stratification (any of the following may indicate possible unstable angina): - Hypotension - ST elevation - 4 mm ST shift - early positive - global risk positive - widespread ischemia on imaging
RSV Dx
Hx and PE viral testing not recommended CXR for severe cases
Varicocele Grading Scale:
I: palpable only w/ Valsalva maneuver II: not visible on inspection, but palpable on standing III: visible on gross inspection
ICD / ViV pacer qualifications
ICD: - EF < 35% and class II or III symptoms - if nonischemic, must have symptoms for > 3 mths and be on optimal medical therapy BiV: - Wide QRS (>=0.13) - Class II to IV HF - on optimal medical therapy - ejection fraction < 35%
GLP-1 receptor agonist route of administration
INJ (pen)
Low back pain physical exam component
INSPECTION: 1. Kyphosis/ lumbar lordosis (standing up straight) 2. scoliosis, scoliometer > 7 degrees (bend forward to touch your toes) PALPATION: 1. palpate spines looking for tenderness 2. palpate paraspinal muscles (usually suggests paraspinal muscle strain) PROVACATIVE TESTS: 1. Tripod Test 2. Straight leg sign
BZD schedule
IV
at what Tanner Stage does female produce secondary mound
IV
Status Asthmaticus treatment
IV fluids, albuterol (xopenix), steroids, epinephrine, oxygen
Magnesium Sulfate vs wheezing
IV magnesium sulfate relaxes smooth muscle and reduces wheezing -it has been advocated in the past for tx of acute asthma. Mg can relax smooth muscle and hence may cause bronchodilation by competing w/ Ca at Ca mediated smooth muscle binding site. -Usually 1 g or a maximum of 2.5 grams during the initiation of therapy may be considered.
Meningitis tx
IV penicillin G and ceftriaxone
QT interval range
In general, the normal QT interval is below 400 to 440 milliseconds (ms), or 0.4 to 0.44 seconds. Women have a longer QT interval than men.
Cortisol level at morning vs night
In most people, cortisol levels are highest in the morning when they wake up and lowest around midnight.
Bisphosphonate MOA
Inhibit osteoclastic bone reabsorption
PTU moa
Inhibits peroxidase mediated oxidation, organification, and coupling steps of thyroid hormone synthesis Inhibits conversion of T4 to T3
Streptococcal Pharyngitis tx
Initial: Penicillin VK - children (<27 kg): 250 mg PO TID x 10 days (BID dosing sufficient if good compliance) -adolescents and adults (>27 kg): 250 mg PO QID or 500 mg PO BID x 10 days Penicillin G benzathine: - children <60 lb (27 kg): 600,000 units intramuscularly 1 dose - children ≥60 lb and adults: 1.2 million units IM 1 dose Amoxicillin: - 50 mg/kg PO QD (max 1,000 mg/dose or 25 mg/kg PO BID (max = 500 mg/dose) Alternatives: Zithromax - children: 12 mg/kg PO once daily for 5 days (max = 500 mg/dose) - adults: 500 mg PO once first day, 250 mg PO QD next 4 days Cephalexin if mildly allergic to PCN *Newer macrolides are effective against streptococcal pharyngitis but also more expensive and unproven at preventing rheumatic complications. *Macrolide-resistant strains of GAS are currently <10% in the United States but more prevalent worldwide.
What are typical ages when child starts toilet training
Initiation of toilet training before 27 months of age is not associated with earlier completion of toilet training, suggesting little benefit to beginning training before this age
Chickenpox (Varicella) and Shingles (Herpes Zoster) Dx
Inspection of skin Lesion Confirm w/ - Blood Test (Varicella AB IgM or PCR to look for viral DNA) this is now preferred over Tzanck Test - Tzanck Test (Multinucleated Giant Cells in Fluid of Vesicles)
The leading cause of death as of 2018
Ischemic heart disease -followed by stroke
Azo availability
It is available over-the-counter (without a prescription or OTC) in lower strengths, and with a prescription for higher strengths.
Acetazolamide MOA for altitude sickness
Its mechanism is via inhibition of the carbonic anhydrase enzyme which counteracts the respiratory alkalosis which occurs during ascent to altitude. It facilitates the excretion of bicarbonate in the urine. As a result, acetazolamide hastens acclimatization and helps prevent high altitude disorders
HTN first line for general nonblack population, including those w/ diabetes
JNC 8: thiazide diuretic, CCB, ACEI, ARB
Polymyalgia Rheumatica PE findings
Joint examination: - ROM affected (shoulder, cervical spine, hip may be limited. Restricted shoulder motion is especially common (classic finding is inability to actively abduct the shoulders past 90 degrees)) NO MUSCLE WEAKNESS
UTI urine culture positive when....
KNOW THAT UTI IS 100,000 (10 x 5) CFU'S TO BE DIAGNOSED in non preg patient and 10 x 3 in preg patient
Attapulgite aka
Kaopectate
Clonazepam brand name
Klonopin
how to read PSA when pt is on finasteride
Longitudinal results from the Prostate Cancer Prevention Trial suggest that PSA values should be corrected by a factor of 2 for the first two years of finasteride therapy and by 2.5 for longer-term use inasteride and dutasteride, inhibitors of 5-alpha-reductase, produce an approximately 50 percent or greater decrease in serum PSA during the first three to six months of therapy finasteride lowers PSA but cancer is still there...
Butenafine brand
Lotrimin Ultra
Amytrophic Lateral Sclerosis is also called
Lou Gehrig's disease
USPSTF Lung Cancer screening recommendation
Low dose CT scan in adults aged 55 to 80 y/o who have a 30 pack year smoking hx and currently smoke (or quit withint he past 15 yrs) D/c screening once a person has not smoked for 15 yrs or develops a health problem that substantially limits life expectancy or willingness to have curative lung surgery
diverticulosis cause
unclear low fiber diet -> constipation -> herniation
Polymyalgia Rheumatica labs
Major Markers: -ESR may be elevated -CRP nearly always elevated (more useful marker than ESR) -Creatine Kinase will remain normal (b/c little damage to muscles) Other labs: -CBC (anemia may be noted) -CMP including BUN, CRE, Ca+, Phosphate -LFT -rheumatoid factor -urinalysis -thyroid stimulating hormone
Pregnancy pretravel care
Make appt w/ doctor (possible Obstetrician) for pretravel care at least 4-6 wks before pt leave. get health insurance in order; check w/ your insurance company; consider getting supplemental travel health insurance and make sure polilcy covers the baby as well; make sure to get policy that cover medical evacuation if traveling to a remote area.
Iron normal range
Male: 80 - 180 mcg/dL Female: 60-160 mcg/dL Newborn: 100-250 mcg/gdL Child: 50-120 mcg/dL
Herpes dx:
Many POCT available commercially HSV PCR higher sensitivity than viral culture (viral culture is collected by unroofing for fluid culture)
pulmonary rehabilitation
Medically supervised program that includes exercise training, health education, breathing techniques for people who have certain lung conditions or lung problems d/t other conditions
medicare C AKA
Medicare Advantage Plan
Pediatric Constipation causes (other than functional)
Medications - Anticholinergic agents (antihistamines) - Cation-containing agents (Iron supplement) Underlying organic causes: - Metabolic or endocrine disorders (hypothyroidism, renal failure) - Electrolyte imbalances (hypercalcemia, hypokalemia) - Neuromuscular disorders (Spina bifida) - Colon diseases (Inflammatory bowel disease)
Melathion 0.5%
Melathion 0.5% is available for the tx of head lice, not scabies
Baker Cyst Symptoms
Most cysts are small, asymptomatic, not clearly evident on physical examination, and detected only by imaging studies performed because of unrelated joint symptoms when symptomatic, s/s include... 1. swelling behind your knee 2. knee pain 3. stiffness and inability to fully flex the knee 4. discomfort w/ prolonged standing and w/ hyperflexion of the knee 5. symptoms and swelling may be worsened by activity 6. Symptoms due primarily to an associated joint disease may also occur, such as instability due to internal derangement or joint pain from inflammatory arthritis or osteoarthritis (OA). In some patients, these are the major or only symptoms present. *easier to visualize with standing up; difficult to visualize laying down
TRUE or FALSE: is it ok to get cast wet? why or why not?
Mostly no (depends on the different types of cast), A wet cast can lead to skin irritation or infection. -*can get wet: fiberglass cast w/ waterproof liner -*cannot get wet: plaster casts and fiberglass cast w/ conventional padding
Sjogren Syndrome tx
Mostly supportive Dry eyes - periodic use of artificial tears Artificial saliva, daily fluoride, anti fungal therapy *Increased risk for lymphoma is 20-40x higher... usually non-Hodgkins B-cell lymphomas*
Atopic Dermatitis Dx Criteria
Must have: -evidence of pruritic skin per pt or family report Then 3 or more of the following: -Xerosis cutis within 1 yr -Hx skin crease involvement -Hx asthma or hay fever(FMH atopic disease in 1st degree relative for children < 4 y/o) -onset of rash before two years of age 2 -visible dermatitis involving flexural surfaces (for those under 4)
atypical pneumonia causes
Mycoplasma pneumoniae Legionella bacterium Chlamydia bacterium
nearsightedness AKA
Myopia
Acamprosate moa
NMDA antagonist- blocks the NMDA receptor for glutamate, aiming to slow neurodegeneration can be administered immediately following acute withdrawal
Narcolepsy patho
Nerves in hypothalamus that produce Orexin A & B (aka Hypocretin 1 & 2) are attacked by autoimmune system -> 5 key symptoms 1. daily sleepiness 2. cataplexy 3. inability to move at start or end of sleep 4. vivid hallucinations around edges of sleep 5. fragmented sleep
FDA Category B
No adequate human studies BUT no risk of animal fetal harm OR no risk to human fetus BUT positive animal fetal harm
Mittelschmerz tx
No specific tx necessary NSAIDSs for pain
Is it harmful to have an extra dose of hepatitis A vaccine or to repeat the entire hepatitis A vaccine series?
No, getting extra doses of Hep A is not harmful
If I have had hepatitis A in the past, can I get it again?
No, p/s Hep A infx and subsequent recovery lead to AB development (will protect for life)
Can Coumadin be given during pregnancy?
No, FDA Category X
Lyme disease: would you do serological test on pt w/ Erythema Migrans?
No, pt who present w/ an EM lesion will likely be seronegative. Also, serologic testing after tx is generally not indicated, since pts w/ EM who are tx'ed early in their course may not develop an AB response
transthoracic echocardiography
Non-invasive ultrasound test used to measure ejection fraction and examine size, shape, and motion of cardiac structures.
OA tx
Nonpharm (mainstay) - Lose wt (10% wt loss significant improvement in s/s) - braces and foot orthoses - rest - education (etiology, risk factors especially modifiables, expected prognosis) Pharm - Only use when s/s present (routine use not effective) - use of acetaminophen as first line not recommended d/t safety concern and lack of efficacy for musculosksletal pain -1st line topical NSAID (preferred) or Capsaicin -if persistent after 1st line, reevaluate for alterantive dx or progression to moderate/severe knee OA; optional trial of adjunctive measures -duloxetine can be given if pt not a candidate for PO NSAID
Nausea treatment
Nonpharm: - Use a cool damp cloth on the forehead, neck, and wrists - Ginger seems to help w/ digestive system OTC: - Dramamine - Meclizine - Benadryl Rx: - Scopolamine - Zofran - Promethazine (Phenergan)- severe sedation - Metoclopramide- moves gastric content faster
Thyroid dysfunction is linked to _______ anemias.
Normocytic
Osteoarthritis Tx:
Nonpharmacological - lose wt - moderate exercise (Transition to non-weight-bearing exercises (i.e., elliptical, stationary bike, swimming) Exercise must be maintained; benefits are lost 6 months after exercise cessation. - physical therapy ( Core strengthening for hip OA and knee muscle strengthening for knee OA decrease joint reactive forces and can relieve pain; Quadriceps-strengthening exercises relieve knee pain and disability; Periscapular strengthening and range of motion exercises for shoulder arthritis) - Bracing, joint supports, or insoles in patients with biomechanical instability - For knee OA in particular, several nonpharmacologic modalities are strongly recommended: aerobic, aquatic, and/or resistance exercise and weight loss. Pharmacological (aim to reduce pain and inflammation) -FIRST LINE PAIN CONTROL: tylenol 2 tabs (325 mg or 500 mg) q 4-6 hrs PRN or 2 tabs Tylenol arthritis extended relief cap (650mg) q 8 hrs PRN, not to exceed 3000 mg q 24 hrs; if no relief from Tylenol or TOP NSAID, use Naproxen or Ibuprofen (w/ PPI) given 2-4 wk trial (Celebrex is 2nd line for OA; Tramadol/opioid is 3rd line for OA) - 1 or few joints: TOP NSAID, Capsaicin also available if TOP NSAID not effective - multiple joints: PO NSAID - multiple joints and PO NSAID contraindication: duloxetine - Diclofenac gel (Voltaren gel) 4 gram applied to affected joint 4 x daily works great - Topical NSAIDs and capsaicin as alternatives to oral analgesic/anti-inflammatory medications in knee OA Surgery: - total joint replacement (highly effective, when other therapies have been tried and failed) *TOP Capsaicin works well for hand, requires frequent applications-, burns because of interaction of capsaicin w/ receptors. doesn't really work well for hip *PO Glucosamine chondroitin is no better than placebo *hyaluronic acid intraarticular injection controversial for knee and hip OA and demonstrates only small superiority over intraarticular placebo *(contradictory per associations) Acetaminophen often not recommended d/t negligible relief *glucocorticoid intraarticular injection not routinely recommended d/t the short duration of its efx (approx 4 wks) and evidence of deleterious efx on the hyaline cartilage and may accelerate OA progression *Rubefacients (e.g., oil of wintergreen) are not recommended.
Tamiflu generic name
Oseltamivir
Pneumococcal vaccine schedule
PCV 13: 2, 4, 6, 12-15 mths
Follicular phase is composed of what two events
Period and Proliferative Phase
Gout is also known as ___ when it involves the big toe
Podagra
strep dx
Rapid Strep
PTU BBW
Severe liver injury, acute liver failure, death
COPD tx for group D
Refer to pulmonologist ASAP Initial therapy: LAMA If further exacerbation: LAMA + LABA (preferred) OR LABA + ICS (fluticasone-salmeterol) if further exacerbation after 1st step up: LAMA + LABA + ICS If further exacerbation after 2nd step ups: consider Roflumilast (phosphodiesterase inhibitor) if FEV1 < 50% PV and pt has chronic bronchitis OR consider macrolide (in former smokers)
Metoclopramide brand name
Reglan
short acting insulin list
Regular (Humulin R, Novolin R)
Prehn's Sign
Relief of pain when the scrotum is lifted, indicates inflammation of the epididymis.
orthostatic hypotension causes
Reduced blood volume Medications Aging Immobility, extended bed rest Autonomic nervous system dysfunction Treatment depends on identifying a cause
Second Generation Antipsychotics AE's
Reduced incidence of motor dysfunction and hyperprolactinemia vs first gen antipsychotic *Increased incidence of metabolic abnormalities: wt gain , diabetes, hyperlipidemia
docusate sodium moa
Reduces surface tension of the oil-water interface of the stool resulting in enhanced incorporation of water and fat allowing for stool softening
MIni Cog Test result
Recall 3 = not demented Recall 1-2, clock normal = not demented Recall 1-2, clock abnormal = demented recall 0 = demented
Chlamydia Recommended regimens, Alternative regimens
Recommended Regimens: *-Azithromycin 1 gram PO in a single dose OR* -Doxycycline 100 mg PO BID for 7 days *Alternative regimens -Erythromycin base 500 mg PO QID for 7 days -Erythromycin ethylsuccinate 800 mg PO QID for 7 days -Levofloxacin 500 mg PO QD for 7 days -Ofloxacin 300 mg BID for 7 days
Myocardial Infarction treatment
Reduce cardiac demand. Oxygen therapy Analgesics Anticoagulants Thrombolytic agents may be used. Tissue plasminogen activator Medication to treat: --Dysrhythmias, hypertension, congestive heart failure --Cardiac rehabilitation begins immediately.
21-21 y/o w/ ASC-US finding, next step?
Repeat Cytology in 12 mths - if repeat cytology shows ASC-US or more severe lesion, receive colposcopy HPV testing can also be done but repeat cytology is preferred
21-24 y/o w/ LSIL finding, next step?
Repeat Cytology in 12 mths - if repeat cytology shows ASC-US or more severe lesion, receive colposcopy HPV testing can also be done but repeat cytology is preferred
Roth spot
Representing white centered retinal hemorrhage, this finding was initially described in infective endocarditis, but also can be seen in systemic lupus, diabetes and leukemia (and others)
telogen
Resting phase of hair growth, has no transparent sheathe, has a bulb
which class of med has nickname "Insulin sensitizer"?
Thiazolidinedione
anagena
The period of active growth of hair (has a transparent sheathe around the follicle
at 12 wks gestation, the uterus fundus should be at what level
at symphis pubis
Fishy vaginal odor may indicate...
bacterial vaginosis
chronic respiratory failure def
chronic inability of the respiratory system to maintain the function of oxygenating blood and remove carbon dioxide from the lungs pCO2 > 50 with non-acute pH (7.35 - 7.45) pO2 < 50 with non-acute pH (7.35 - 7.45)
miscarriage def
dead before 20th gestational week
fifth disease aka
erythema infectiosum
Aminoglycoside list
gentamicin, tobramycin, amikacin, streptomycin
Medicare A covers
hospital insurance
Chronic cough duration
over 8 weeks
Toxoplasmosis screening
routine screening not recommended, except in endemic areas
Hand foot mouth disease rash characteristic
small vesicles on erythematous base on the hands feet and inside the mouth first lesions appear as painful sores on the buccal mucosa, gingiva, soft palate, and tongue
epstein pearll
small white cysts on hard palate of newborn common, disappear in few weeks
plan b when to take
take it ASAP, can prevent pregnancy within 5 days
UTI most common pathogens
1. E. coli 2. Klebsiella pneumoniae 3. Proteus Mirabillis 4. Enterococcus faecalis 5. Staphlococcus saprophyticus
Amytrophic Lateral Sclerosis diagnostic workup
1. Electromyography 2. Nerve conduction studies 3. MRI 4. Lumbar puncture 5. Lyme titer and other serologies 6. increased Creatinine kinase (d/t muscle atrophy)
Incretin mimetic list (2)
1. Exenatide (Byetta, Bydureon) 2. Liraglutide (Victoza, Saxenda) 3. Trulicity
Pediatric Constipation tx <constipation treatment, constipation management>
1. First step: disimpact the lodged stools *can use PO or SUPP- note PO method is slower *PO and SUPP are relatively equal in effectiveness -Miralax (PEG3350) or prune juice work great (per Dr. Huang and Dr. Plato-Johnson) - Miralax 1.5 g /kg/day - can use rectal thermometer (if not, manual disimpact may be needed) - alternatively use Glycerin SUPP or Bisacodyl SUPP 0.5 - 1 SUPP/ 12-24 hrs - alternatively, PO osmotically active carb such as prune juice 1-3 ml/kg/day divided to 2 doses a day 2. Next step maintenance laxative tx and behavior therapy to achieve regular evac and avoid recurrent constipation Maintenance laxative: - Miralax 0.5-0.8 g/kg/day up to 17 g per day Behavioral: - regular toilet sitting (twice daily for half an hour per session, regardless of whether they feel the desire to go) - Stool Diary (track time & date the child passes stool) - Reward-based system such as sticker chart 3. Diet Modifications Diet: - increase wholte grains, fruits, vegetables - fiber intake 0.5 g/kg/day (up to 35 g/day for ALL CHILDREN) - adequate fluid intake (infants weighing 3.5-10 kg needs 100 mL/kg; children weighing 11-20 kg need 1000 mL + 50 mL/kg over 10 kg; children weighing over 20 kg need 1500 mL + 20 mL/ kg over 20 kg) Max 2400 mL daily 4. Gradual tapering and withdrawal of laxatives
Alpha Glucosidase Inhibitor SE
1. GI disturbance (increased gas, bloating, diarrhea d/t decreased carb absorption in small intestine)- main severe SE 2. decreased Fe absorption-> anemia 3. hepatic dysfunction w/ long-term use (monitor LFTs)
Metformin SE
1. GI disturbances (common and severe) - diarrhea - N/V - abdominal cramps - wt loss (useful in overweight or obese patients) *extended version of Metformin has less GI discomfort 2. lactic acidosis (rare but possible) 3. Vitamin B12 deficiency (will manifest as paresthesia, etc) *LOW HYPOGLYCEMIC RISK NOTED
Constipation PE
1. General: - Assess growth & development - Abdominal exam: stool may be felt in the LOWER LEFT QUADRANT, abdominal distension, abdominal or pelvic masses - Back (r/o Spina Bifida noted w/ hair tufts or dimples) 2. evaluate perianal area (appearance and location of the anus) - Decreased anal sphincter tone - Anal fissures (will cause great deal of pain) 3. Digital rectal exam (for specific cases) (in children w/ normal neonatal courses or clear witholding bbehaviors, or in whom trauma is suspected, rectal exam may be deferred) 4. Neuro (sensory loss or motor weakness, absent cremateric reflex)
preeclampsia common s/s
1. HTN 2. wt gain 3. proteinuria 4. *edema of the face and upper extremities 5. headache 6. blurred vision
Constipation things to rule out
1. Hirschprung disease -in infancy: doesn't pass meconium w/in first 48 hrs; abdominal distention; refuses to feed; bilious vomiting - on PE: digital rectal exam (empty rectum w/ increased anal tone) 2. Spinal cord abnormality 3. Metabolic disorders - Hypothyroidism (Thyroid studies) - Hypercalcemia, hyperkalemia (electrolyte) - Diabetes (fasting glucose level) - Diabetes insipidus (serum and urine osmolarity) 4. Imperforate anus -in infancy: doesn't pass meconium w/in first 48 hrs; abdominal distention; refuses to feed; bilious vomiting 5. meconium ileus -in infancy: doesn't pass meconium w/in first 48 hrs; abdominal distention; refuses to feed; bilious vomiting
Fall risk factors
1. Hx fall 2. lower extremity weakness 3. Arthritis 4. psychotroic drug use includes sedative, hypnotics, tranquilizers, narcotic analgesics 5. Hx stroke 6. orthostatic hypotention 7. dizziness 8. anemia 9. poor vision 10. Cognitive dysfunction 11. Urinary frequency or receiving diuretics
Irritable Bowel Syndrome subtypes <IBS subtypes>
1. IBS w/ predominant constipation 2. IBS w/ predominant diarrhea 3. IBS w/ mixed bowel habits - more than 1/4 of all abnormal BM were constipation and more than 1/4 were diarrhea 4. IBS unclassified
Rotavirus Absolute Contraindications
1. Immunodeficient individuals 2. Children w/ hx intussusception (low risk of intussusception noted w/ this vaccine)
Uveitis Ddx
1. Keratitis 2. Conjunctivitis 3. Episcleritis, scleritis 4. Acute clsoed-angle glaucoma 5. Floaters *Idiopathic iritis should be suspected when there is acute onset of pain and photophobia in a healthy individual who does not have systemic disease
Carotid Artery Stenosis ddx
1. Monoparesis 2. TIA 3. CVA 4. Multiple sclerosis 5. peripheral neuropathy 6. cerbvical spinal stenosis 7. myasthenia gravis 8. lead poisoning
Neuroleptic Malignant Syndrome characteristics
1. Muscle Rigidity 2. Elevated temperature 3. Altered consciousness 4. Autonomic dysfunction *this is life threatening complication that occurs in up to 1% of pts w/ antipsychotic drugs
DPP-4 inhibitor SE
1. N/V/D 2. Flu-like symptoms (pharyngitis, rhinorrhea, nose and sinus congestion, headaches, URI) *wt neutral *no hypoglycemia risk
epididymitis tx
1. NSAID for pain control 2. 2ndary to chlamydia/gonorrhea: Ceftriaxone 250 mg IM for 1 dose PLUS Doxycyline 100 mg PO BID 7 days 3. if not due to STD: consider, Bactrim DS BID for 10 days, OR Cipro 500 mg PO BID, OR Floxin 300 mg PO BID for 1 0 days 4. nonpharm management: elevate scrotum (wear athletic supporter, ice pack as tolerated, bedrest) *Quinolones are no longer used if STD pathogens such as N. gonorrheoeae are suspected (d/t increased resistance) *Lack of improvement in 3 days of tx warrants prompt re-evaluation of dx and tx regimen
herpes pt education
1. NSAID or tylenol might help w/ pain 2. ice pack helps with pain and burning sensation 3. avoid sex during contagious time 4. use condom 5. hygiene
Full Cranial Exam
1. Olfactory: - ask about sense of smell 2. Optic: - visual acuity - ophthalmic exam of fundi - Confrontation exam for visual field 3/4/6. Oculomotor, Trochlear, Abducens - inspect eyelids for drooping - extraocular eye movement (make an H) -Inspect - remember the chemical formula LR6SO4, everything else is CN 3... 5. Trigeminal - sharp/dull on opthalmic, maxillary, and mandibular branch bilaterally - palpate jaw muscles for tone and strength when pt clenches teeth 7. Facial - facial expressions (smile squint eyes, raise your eyebrows, puff out your cheeks) 8. Acoustic - whisper testing - Weber - Rinne 9/10 Glossopharyngeal, Vagus - say "ah"- check for uvula rise symmetrically, gag reflex may be verbalized 11. Accessory - shoulder shrug against my hand (checking trapezius muscle strength) - turn head against head (checking sternocleridomastoid muscle strength 12. Hypoglossal - stick out tonegue, move it side to side (for symmetry, tremor, atrophy) *Cerebellar function - finger to nose or alternating movement *DTR - bicep - tricep - patellar
Pregnancy Supplement recommendation
1. Omega 3 fatty acids 2. Iron intake increased from 15-30 g/day 3. Folic acid: increase folate consumption to 400-800 mcg/day 4. Calcium 1000 mg/day for women aged 19-50, for adolescents upto age 18, 1300 mg daily 5. Vit D 600 IU /day for all women 6. Fiber 28 grams/day
Proton Pump Inhibitor (PPI) list:
1. Omeprazole (Prilosec) 2. Omeprazole IR w/ Na+ HCO3- (Zegerid) 3. Pantoprazole (Protonix) 4. Lansoprazole (Prevacid) 5. Esomeprazole (Nexium); closely related to omeprazole 6. Dexlansoprazole (Dexilant) 7. Rabeprazole (Aciphex)
Disaster Response phases (4)
1. Planning: creating a written plan, exercising, practicing, and revising the plan 2. Mitigation: reducing the effects of the disaster before the actual event, including evacuation 3. Response: activation, organization of command and scene assessment implementation 4. Recovery: restoration of order
Medial Tibial Stress Syndrome (Shin Splint) tx
1. RICE (severals wks of rest recommended) 2. do not run until walking is pain free. If aerobic exercise is desired, recommend lower impact exercises (e.g. swimming, stationary bike). If stress fracture suspected, avoid exercising 3. take a look at the shoe 4. contact PT if no relief in 3 wks 5. imaging test of choice: bone scan and/or MRI. 6. If possible stress fracture, refer to orthopedic specialist
Acute Cholecystitis workup
1. RUQ US (gold standard) 2. CBC w/ diff (WBC elevated) 3. CHEM 20 4. hCG (pregnancy) 5. ECG 6. UA (UTI) 7. blood culture
Meglitinide list (2)
1. Repaglinide (Prandin) 2. Nateglinide (Starlix)
Thiazolidinedione list (TZD)
1. Rosiglitazone (Avandia) 2. Pioglitazone (Actos) - used more than Avandia *TZD is rarely used nowadays...
DPP-4 inhibitor list (2)
1. Sitagliptin (Januvia) 2. Saxagliptin (Onglyza)
CVA risk factors <stroke, transient ischemic attack, TIA>
1. TIAs are risk factor for recurrent risk of stroke 2. Drug abuse 3. Smoking 4. DM 5. Obesity 6. Sedentary lifestyle 7. elevated serum cholesterol
Cephalosporin treats...
1. Uncomplicated community-acquired skin/soft tissue infx's 2. Uncomplicated UTI's 3. Surgica lwound prophylaxis
Uveitis PE
1. Visual acuity may be decreased in the affected eye 2. Perilimbal injection, increases in intesity as it approaches the limbus (reverse of the pattern seen in conjunctivitis, in which the most severe inflammation occurs at a distance from the limbus) 3. lid, lashes, lacrimal ducts normal 4. direct photophobia or consensual photophobia (consensual photophobia is typical of iritis, whereas photophobia d/t more superfical causes, such as conjunctivitis, is directgt but not consensual) 5. pupillary miosis common
General Anxiety Disorder: FDA approved Benzos
1. Xanax 2. Librium 3. Ativan 4. Valium 5. Serax 6. Tranxene Only 2 that professor is comfortable using are Ativan and Valium
Misoprostol AE
1. abdominal pain 2. flatulence 3. diarrhea
recurrent UTI management
1. abx prophylaxis can be used but is generally not recommended as first line preventative strategy. abx is an appropriate intervention for frequent recurrences 2 or more in 6 mths 2. increase fluid 3. cranberry juice seems to help w/ prevention
Carotid Artery Stenosis risk factors
1. age 2. personal or family hx stroke, angina, MI, PAD 3. HTN 4. Hypercholesterolemia 5. DM 6. Obesity 7. Tobacco abuse 8. Sedentary lifestyle
MMRV contraindication
1. allergy to gelatin or neomycin 2. pregnancy 3. immunodeficiency or family hx immunodeficiency
Pyrazinamide AE
1. arthralgia 2. hyperuricemia/ gout 3. hematologic toxicity 4. fever 5. hepatitis 6. increased serum Fe
Exercise induced bronchoconstriction pt education
1. avoid cold dry weather (reduces stimulus) 2. Severe attack: Take two to six puffs of a rescue medication, depending upon how much the individual can tolerate at once without becoming too jittery 3. Wear medical identification
Actinic Keratosis Prevention
1. avoid sun exposure or tanning bed 2. wear sunscreen with SPF 15 or higher 3. wear clothing that protect skin from sun
Molluscum contagiosum tx option
1. benign watchful onitoring 2. direct lesional trauma 3. antiviral therapy 4. immune response stimulation healthy children, a major goal is to limit discomfort, and benign neglect or minor, direct lesional trauma is appropriate. In adults who are more motivated to have their lesions treated, cryotherapy or curettage of individual lesions is effective and well tolerated.
baby hiccup: management
1. burp your baby by taking a break (take a break from feeding to burp your baby; burp your baby when you are switching breasts or after every 2-3 ounces if bottle-fed) 2. give them a pacifier (if baby wasn't feeding, sucking on pacifier may help relax the diaphragm and stop the bout of hiccups) 3. let the hiuccups runs their course 4. feed baby gripe water (has herbs so check alelrgies)
pertussis phases
1. catarrhal ( non specific URI sx. most contagious phase) - low-grade fever - rhinorrhea - mild cough 2. Paroxysmal : - whoop (hurried and deep) - post-tussive emesis. 3. convalescent phase ~ 2-3 wks- - cough slowly improve, paroxysms fade, airway heals
diabetes monitoring points
1. close f/u, weekly first mth, mth until stable, move toward q 3 mths f/u 2. instruct about s/s hypoglycemia 3. monitor blood glucose at home (finger sticks) 4. assess A1C- baseline and q 3 mths 5. monitor annually- lipids, UA - Sulfonylureas- annual CBC, renal function - Metformin- electrolytes, ketones, blood pH, lactate, pyruvate, creatinine - Thiazolidinediones- LFT - Alpha-glucosidase inhibitor LFT
Multiple Sclerosis epidemiology
1. common in persons of western European lineage who live in temperate zones 2. No population w/ a high risk exists between latitudes 40 degrees 3. begins most commonly in young adulthood, most commonly dx'ed between 20-50 years 4. female 2-3 times more likely 5. asians and persons of African descent at lower risk 6. most common cause of disability in young adults
Concussion signs and symptoms
1. confusion- pt often appears confused or blank expression or blunted affect 2. delayed response and emotional changes- delayed response to simple questioning may be demonstrated along with emotional lability; the emotional lability may become more evident as the athlete attempts to cope w/ his confusion 3. pain/dizziness- pt reports associated headache and dizziness 4. visual disturbances- seeing stars, blurry vision, or double vision 5. amnesia- pretraumatic (retrograde) and posttraumatic (antegrade) amnesia may be present; usually, duration of retrograde amnesia is quite brief, while duration of posttraumatic amnesia is more variable (seconds to mins), depending on injury 6. signs of increased ICP- hx persistent vomiting may suggest a significant brain injury w/ associated elevated ICP; other signs of increased ICP include worsening headache, increasing disorientation, and a changing lvl of consciousness
types of birthmarks
1. congenital melanocytic nevi (mole) 2. cafe-au-lait macules 3. nevus 4. strawberry spots 5. stork bite marks
Gonorrhea Hx
1. date of last menstrual period 2. details of parity 3. hx ectopic pregnancies 4. hx STD
Cimetidine Side effects
1. diarrhea 2. confusion 3. dizziness 4. headache 5. dysrhythmias 6.hepatic abnormalities 7. gynecomastia 8. depression
TZD DI's
1. drugs that induce, inhibit, or are metabolized by CYP2C8 (including estrogen) 2. pioglitazone can potentiate hypoglycemic effects of other drugs (including insulin) 3. incidience of wt gain and edema are doubled by insulin
Fibromyalgia management
1. education about the uncertainty of the pathogenesis 2. Aerobic cardiovascular fitness training (low impact aerobic activities such as walking, biking, swimming or water aerobics are most successful) 3. initiate low dose TCA (Amitriptyline 5-10 mg qhs, increase by 5 mg q 2 wks); in pt w/ particularly severe fatigue or depression, SSRI is a reasonable alternative to TCA for initial therapy; Antiepileptic (Pregabalin, gabapentin) and Muscle Relaxants (cyclobenzaprine) can be used as well
Thiazide diuretic SE / AE
1. elevated plasma glucose / hyperglycemia (careful w/ diabetics) 2. elevated cholesterol and LDL 3. elevated uric acid (can precipitate a gout attack) 4. Hypokalemia (severe muscle weakness, arrhythmia)
Diverticulitis indications for hospitalization
1. evidence of severe diverticulitis (e.g. systemic signs of infx or peritonitis) 2. inability to tolerate oral hydration 3. failure of outpatient therapy (e.g. persistent or increasing fever, pain, or leukocytosis after 2-3 days; these pts are not someone who you want to follow them up for two weeks) 4. immunocompromise or significant comorbidities 5. pain severe enough to require parenteral narcotic analgesia
General Anxiety Disorder criteria
1. excessive anxiety and worry occurring more days than not >= 6 mths 2. at least 3/6 s/s: - restlessness - fatigue - difficulty concentrating - irritability - muscle tension - sleep disturbances
Obstructive Sleep Apnea symptoms
1. excessive daytime sleepiness 2. inability to concentrate 3. irritability 4. loud snoring, gasping, choking, snorting, interruption in breathing while sleeping less common: 1. nonrestorative sleep 2. nocturnal restlessness 3. morning headaches 4. sleep maintenance insomnia, and nocturia
Folate Deficiency Anemia f/u
1. f/u in 2 wks to determine the response to therapy and then every mth until stable 2. hct should rise within 1 wk of initiation of therapy 3. rapid increase in reticulocyte w/ peak in 7-10 days after therapy begins
pregnancy-induced HTN: common s/s (name 4)
1. facial edema and the upper extremities 2. weight gain 3. blurred vision 4. elevated blood pressure 5. proteinuria 6. headaches
Adult Constipation risk factors
1. female sex (incidence threefold in female; constipation incidence increase during menstrual period) 2. older age 3. inactivity/ sedentary lifestyle 4. low caloric intake 5. low-fiber diet 6. polypharmacy 7. non-whites (1.3 times more likely) 8. low socioeconomic status (much more likely) 9. geographic distribution (especially in US) 10. rural area 11. cold environment
Folate Deficiency Anemia diagnostic workup
1. folic acid decreased or < 2 ng/ml (normal adult: 2-20 ng/mL) 2. elevated homocysteine confirms B9 deficiency 3. CBC w/ diff 4. B12 (it is common for pts who have a B12 deficiency to have a folate deficiency. Measure B12 lvl in pts who have folic acid deficiency anemia)
Adult Constipation types and causes <constipation causes>
1. functional (primary) - Defined by Rome III diagnostic criteria and can be further divided into normal transit, slow transit, and outlet constipation 2. secondary d/t medical conditions or medication use - More common: antacids, especially w/ Ca+, Iron supp, opoids, CVA, depression, DM, hypothyroidism, IBS - Less common: anticholinergic agent, antidiarrheal, antihistamines, antiparkinsonian, antipsychotic, CCB, Ca supp, diuretics, NSAID, sympathomimetics, TCA, anal fissures, autonomic neuropathy, cognitive impairment, colon cancer, hypercalcemia, hypokalemia, hypomagnesemia, immobility, multiple sclerosis, parkinson diseaes, spinal cord injury
Hidradenitis suppurativa epidemiology (5)
1. generally occurs after puberty 2. Female: male- 3:1 to 5:1 3. flare-ups may be a/w menses 4. affects all races 5. family hx w/ mother-daughter transmission
hyperuricemia can lead to what complications...
1. gout 2. urolithasis 3. urate nephropathy
diphtheria character
1. gradual onset w/ low grade fever 2. grayish leathery patches
Meglitinide SE
1. hypoglycemia 2. weight gain
insulin common SE
1. hypoglycemia (s/s: headache, weakness, hunger, sweating, dizziness, anxiety, tachycardia) 2. lipodystrophy 3. wt gain
Loop diuretic se
1. hypokalemia 2. hyponatremia 3. hypomagnesemia 4. low lvl of chlorine 5. pancreatitis, jaundice, and rash 6. ototoxicity (worsens aminoglycoside ototoxicity effx if combined)
Digoxin benefits and Limitations vs HF
1. improves symptoms and clinical status 2. increases ejection fraction 3. increases exercise capacity 4. reduces hospital admissions and ER visits Limitations 1. no change in overall survival 2. increased risk of arrhythmias
Folate Deficiency Anemia management
1. increase dietary folate intake (at least 400 mcg dietary folate ) - green leafy vegetables, meat from animal sources, fruits, nuts, liver, foods containing yeast 2. folic acid 0.4 to 1 mg PO QD until deficiency corrected 3. maintenance dosing of 0.4 mg PO QD
ATP IV giudeline for cholesterol
1. individuals w/ clinical atherosclerotic cardiovascualr disease should be tx'ed w/ high-intensity statin therapy to achieve at least a 50% reduction in LDL cholesterol. 2. individuals w/ LDL-cholsterol lvls > 190 mg/dL, such as those w/ familial hypercholesterolemia should receive tx w/ a high-intensity statin w/ the goal of at least 50% reduction in LDL cholesterol lvls. 3. individuals w/ diabetes aged 40-75 y/o w/ LDL-cholesterol lvls between 70-189 mg/dL and w/o evidence of atherosclerotic cardiovascualr disease should be tx'ed w/ a moderate intesntiy statin (lowers LDL cholesterol 30 - 49 %). Individuals w/ a 10 yr atherosclerotic cardiovascular risk exceeding 7.5% can reasonably tx'ed w a high intensity statin 4. individuals w/o evidence of cardiovascular disease or diabetes but who have LDL-cholesterol lvls between 70-189 mg/dL and a 10 yr risk of atherosclerotic cardiovascular disease > 7.5% should be tx'ed w/ a moderate or high-intensity statin A high intensity statins is the best agent for lowering LDL and can also help to increase HDL.
Rheumatoid Arthritis diagnostic criteria
1. inflammatory arthritis involving 3 or more joints 2. RF + 3. ESR/CRP elevated 4. diseases w/ similar clinical features excluded, particularly psoriatic arthritis, acute viral polyarthritis, polyarticular gout or calicium pyrophosphate deposition disease, and SLE 5. duration > 6 wks *these criteria are consistent w/ the 2010 American College of Rheumatology (ACR)/ European League Against Rheumatism (ELLAR) classification criteria for RA.
Hidranetitis Suppurative PE
1. inspect entire body for inflamed lesions - axillae, groins, perianal region, buttocks, chest, inframmary area, back 2. palpate to determine lesion readiness for I&D 3. Hurley Stage to classify the severity
Diphtheria Tx
1. isolate patient 2. PCN G (or Erythromycin if allergy) 3. assess toxigenicity w/ Elek's Test 4. Diph Antitoxin given to counter the efx of the bacterial toxin
Polymyalgia Rheumatica monitoring
1. keep tabs on GCA s/s, diagnostic eval 2. ESR/CRP- once at baseline, 2 mth post steroid initiation, 3-6 mths thereafter *relapse is common, resume steroid if relapse occurs
Multiple Sclerosis poor prognosis indicator
1. late onset 2. chronic progressive course 3. motor symptoms 4. polysymptomatic onset 5. vertigo
how to screen for Autism in Primary Care
1. listen to parents and take their concerns seriously 2. know that observation of the child during the office visit is probably not sufficient b/c children w/ ASD often are able to manage the social demands of pediatric office visit 3. engage the child in open ended conversation (friendships, what she or he likes to do during play tim)
Pregnancy heart sound
1. louder, widely split S1 2. displaced apical pulse (heart is in a more transverse position) 3. systolic ejection murmur (d/t increased stroke volume)
Leukemia risk factors
1. male > female 2. family hx: most people who get leukemia do not have a family hx; but people w/ relatives who have AML or CLL may be at increased risk 3. age: msot type of leukemia become more common as people get older. But ALL is more common in children than in adults 4. myelodysplastic syndrome 5. congenital conditions (Down syndrome, ataxia-telangiectasia, Bloon syndrome) 6. radiation exposure 7. past chemotherapy: most likel for AML or aLL to develop 8. smoking: higher AML risk
Palpitation: four variables that have been found to be independent of a cardiac etiology
1. male sex 2. description of irregular heart beat 3. hx heart disease 4. event duration > 5 mins * none of the pts w/ 0 predictors had a cardiac etiology *each predictor adds risk
Cataract s/s
1. may be asymptomatic 2.difficulty focusing on objects 3. lower vision at night 4. increase in nearsightedness AKA "Second sight" - However, as the cataract progresses, second sight is lost and both near and distant vision deteriorate. 5. glares or bright lights when driving 6. age related cataracts tend to be bilateral in nature and manifest as blurred or distorted vision
Parkinson's Disease epidemiology
1. mean age at dx is 70.5 y/o 2. 1% in persons > 50 yrs 3. 1% of persons > 60 y/o 4. seen most frequently in European ancenstry 5. rapid increase in incidence after 65 y/o 6. uncommon in persons younger than 40 years 7. 50% more men than woman 8. risk doubles if 1st degree relative has PD
OPV absolute contraindications
1. neomycin allergy 2. pregnancy 3. immunodeficient individuals
IPV absolute contraindications
1. neomycin allergy 2. pregnancy (IPV is not live but still should be avoided)
When to refer HF pts to specialist <HF referral>
1. new onset HF 2. need for an ICD/BiV 3. Worsening or refractory symptoms 4. Hyponatremia (especially <125) 5. high diuretic requirements (>1.5 mg/kg furosemide) 6. Intolerant to guideline-based medicaions 7. worsening renal insufficiency 8. recurrent hospitalization
HFrEF: when to refer?
1. new onset HF (regardless of EF) for eval of etiology, guideline-directed eval and management of recommended therapies, and assistance in disease management 2. chronic HF w/ high-risk features, such as development of 1 or more of the following risk factors - need for chronic IV inotropes - persistent NYHA functional class III-IV s/s of congestion or profound fatigue - sBP <= 90mmHg or symptomatic hypotension - CRE >= 1.8 mg/dL or BUN >= 43 mg/dL - onset of afib or ventricular arrhythmias or repetitive ICD shocks - 2 or more emergency department visits or hospitalizations for worsening HF in prior 12 mths - inability to tolerate optimally-dosed beta blockers and /or ACEI/ARB/ARNI and/or aldosterone antagonist - clinical deterioration as indicated by worsening edema, rising biomarkers (BNP, NT-proBNP, others), worsened exercise testing, decompensated hemodynamics, or evidence of progressive remodeling on imaging - high mortality risk using validated risk model for further assessment and consideration of advanced therapies 3. to assist w/ management of GDMT, including ACEI or ARB therapy w/ ARNI for eligible pts, or to address comorbid conditions such as chronic renal disease or hyperkalemia, which may complicate tx 4. persistently reduced LVEF <= 35% despite GDMT for >= 3 mths for consideration of device therapy in those pts w/o prior placement of ICD or CRT, unless devie therapy contraindicated several more...
Hidradenitis suppurativa risk factors (6)
1. obesity (and metabolic syndrome) 2. smoking (trigger) 3. tight-fitting clothings 4. family hx (30%) w/ strong mother-daughter transmission 5. genetic predisposition to acne 6. Hyperandrogenism in women
Multiple Sclerosis risk factors
1. onset is typically between 20 and 40 years of age 2. twice as often in women. 3. There is a family history (1st degree relative) of MS in many cases. 4. Since MS is an autoimmune disease, there are factors that trigger relapses. • Viruses and infectious agents • Living in a cold climate • Physical injury • Emotional stress • Pregnancy • Fatigue • Overexertion • Temperature extremes • Hot shower/bath
MMRV: use w/ caution in individuals w...
1. prior seizures or family hx seizures (increased risk of febrile seizure w/ this vaccine noted) 2. hx thrombocytopenia
fifth disease stages < erythema infectiosum, Parvovirus B19>
1. prodromal stage- URI infx s/s including low-grade fever, headache, chills, malaise 2. as fever gets better, slapped cheek rash (resolves in 2-3 days) and/or joint pain (arthralgia) or inflammation (arthritis) 3. "slapped cheek" rash; rash moves to the arms and legs become a lacy appearing rash that is flat and appears purple; may last for a few weeks
Gout ddx
1. pseudogout 2. septic arthritis 3. reactive arthritis 4. osteoarthritis 5. cellulitis 6. vasculitis 7. psoriatic arthritis
for afib, warfarin is a reasonable choice in a following circumstance:
1. pts already on warfarin who are comfortable w/ periodic INR measurements 2. pts who are not likely to comply w/ twice daily dosing of many of the NAOCs or for once a day dosing that's not available 3. cost is a concern 4. pts w/ CKD, GFR less than 30 5. pts w/ contraindication to NOAC (like antiepileptic drugs, like pheyntoin, pts w/ HIV on protease inhibitor based antiretroviral tx)
4 groups most likely to benefit from statin therapy are...
1. pts w/ any form of clinical ASCVD 2. pts w/ primary LDL-C lvls of 190 mg/dl or greater 3. pts w/ DM, 40-75 y/o, w/ LDL-C of 70-189 mg/dl 4. pts w/o diabetes, 40 -75 y/o, w/ 10 year ASCVD risk >= 7.5%
Toxoplasmosis transmission route
1. raw/undercooked meat 2. cat feces
Finasteride SE
1. reduced libido 2. decreased ejaculate volume 3. ED in 3-5% of all pts *SE generally well tolerated in most pts, AE may decrease w/ time; AE are reversible w/ tx cessation.
Cheilosis tx plan
1. remove underlying cause. Check if dentures fit correctly; if loose, refer to dentist 2. if yeast suspected, microscopy w/ KOH. If positive (pseudohyphae and spores), tx w/ topical azole ointment (e.g. clotrimazole, miconazle) BID 3. if staph infx suspected, C/S. If positive, tx w/ topical mupirocin ointment BID 4. when infx has cleared, use barrier cream w/ zinc or petroleum jelly applied at night. High rate of recurrence
ACEI contraindication
1. renal artery stenosis 2. renal insufficiency 3. hyperkalemia (since aldosterone is responsible for increasing the excretion of K+. ACE inhibitors can cause retention of potassium) 4. arterial hypotension 5. intolerance (d/t SE)
2 most common shoulder problems seen by PCP are:
1. rotator cuff tendinitis 2. shoulder arthritis
Dementia assessment algorithm step by step
1. screen mental status: - Mini-cog (clock draw test w/ 3 item recall at 1 min) 2. if patient fails Mini-cog, further test w/ MoCa questionnaire, MMSE, or other instruments. 3. perform labs: - CBC w/ diff - TSH - B12 - Electrolyte - CR - Glucose - Ca - Lipids - can consider HIV, syph, heavy metal screen, lyme, csf 4. All pts suspected of Alzheimer should undergo neuroimaging. MRI can demonstrate hippocampal and cortical atrophy in temporal and lateral parietal lobes consistent w/ Alzheimer.
SSRI SE
1. significant sexual SE- anorgasmia, erectile dysfunction, ejaculatory dysfunction 2. wt gain or wt loss, GI upset
Rheumatoid Arthritis s/s
1. soft warm tender joints 2. absent heberden's nodes *3. more proximal joints than distal compared to OA *4. stiffness worse after resting (e.g. morning stiffness longer than 45 mins) *5. relatively rapid onset over wks to mths
COPD workup
1. sputum exam 2. CXR 3. spirometry (gold standard) 4. alpha 1 antitrypsin lvls
plantar fasciitis tx
1. stretching exercises for the plantar fascia and calf muscles, rest, ice (20 mins QID) 2. avoid flat shoes and barefoot walking 3. NSAID short term (2-3 wks) 4. if above measures fail, a trial of a single glucocorticoid injection may be useful if significant pain and disability persist for more than 3 to 4 wks 5. if 1-4 fail, surgery is an option for pts who do not respond adequately to at least 6- 12 mths of nonoperative therapy 6. consider X-ray to r/o fracture, heel spurs, complicated cases 7. refer to podiatrist PRN *vast majority improve w/ only conservative therapy
Psoriasis Risk Factors
1. strong genetic predisposition (40% have a family hx in 1st degree relative 2. smoking (intensity and duration increases risk) 3. obesity and increased BMI 4. infx (Bacterial and viral,Strep throat, HIV) 5. ETOH use disorder 6. Vit D deficiency 7,. Drugs (beta blockers, lithium, antimalarial) 8. cold dry weather
psoriasis nonpharm management
1. sunbathing- leads to improvement 2. eliminate trigger factors 3. daily bath in warm water followed by application of cream or ointment moisture 4. emollient 1-3 times a day are helpful (Eucerin is available as cream or lotion)
Neonatal Conjunctivitis w/ gonorrhea s/s
1. swollen eyelids 2. discharges from eyes - mucus - pus
Acute Cholecystitis s/s
1. tenderness to palpation 2. jaundice 3. ill appearance 4. RUQ or epigastric pain that radiates to the right shoulder or back 5. fever (usually low grade, 99 -101; high fever suggest sepsis) 6. nausea/vomiting 7. anorexia 8. tachycardia *9. + Murphy's sign* 10. pain may be aggravated by the movement, so pt may lie still *often a hx of fatty food ingestion one hour or more before the initial onset of pain.
Hyperuricemia: initial work up
1. thorough hx (medical conditions, diet, lifestyle, drug therapies, toxin, known familial disorders) 2. PE 3. labs (CBC w/ diff, chem profile, careful attention to renal function, electrolyutes, Ca+, LFTs, and UA) *goal is to identify secondary causes and addressthose, thus ruling in the pimary categoryo f hyperuricemia.
General Anxiety Disorder : R/O what somatic causes
1. thyroid 2. asthma 3. copd 4. CHF 5. Anemia 6. hypoglycemia 7. substance use/withdrawal including caffeine and prescribed medications
Carotid Artery Stenosis management
1. tx underlying cause 2. aspirin (mainstay) 3. hyperlipidemia therapy (statin) 4. tobacco cessation 5. carotid angioplasty/stenting 6. surgery
Hyperuricemia Epidemiology:
1. very common - 20-25% of adult men (can begin at puberty 2. smaller proportion of women (generally delayed until after menopause d/t estrogen effx) 3. urate crystal related disease occurs, on average, 2 decades after the initial physiologic increase in urate concentration
BB vs HFrEF limitations
1. will decrease contractility acutely 2. side effx
live vaccines include
1. yellow fever 2. PO typhoid vaccine 3. nasal influenza 4. OPV 5. japanese encephalitis 6. MMR 7. varicella 8. Zoster 9. rotavirus
aPTT normal range when on Heparin
1.5-2.5 x baseline/normal range
Kegel exercise frequency
10 exercises each time 3 times a day (hold to count of 10, rest 10)
Lexapro dosing
10 mg PO once daily; may increase in 1 to 2 wk; MAX 20 mg PO daily; MAX older adults: 10 mg PO daily PEDS: > 12 y/o:L dosing same as adult except increase should be delayed until after 3 wks
baby gains their birth weight back by
10 to 14 days
When does the umbilical cord fall off?
10 to 21 days
NPH dosage initial
10 units at dinner or bedtime - increase 1-2 units every 3-5 days to achieve fasting blood sugar goals
Lantus or Levemir dosage
10 units or 0.2 units/kg QHS - increase 2-4 units q 3-5 days to achieve fasting blood sugar goal
ASCVD percentages def:
10 year risk for ASCVD categorized as: - low risk < 5% - borderline risk 5- 7.4% - intermediate risk 7.5 -19.9% - high risk >= 20%
Copper IUD lasts ______
10 yrs *really doesn't have expiration
# of diapers: 0-1 mth baby
10-12 diapers
acetaminophen dosage for Pediatric
10-15 mg/kg/dose every 4-6 hrs
AST normal range
10-40 units/liter
adequate fluid intake: 3-5 y/o, 10 kg wt
100 mL/kg
PEDS moderate dehydration administration amount and timing
100 ml/kg ORT over 4 hours in physician's office or ER
UTI def in a healthy nonpregnant adult in terms of CFU
100,000 CFU or 10^5 CFU of one organism -in symptomatic pregnant woman, 10^3 CFU /mL is considered a UTI -in catherized pt, 10^2 CFU/ml
adequate fluid intake: 11-20 kg
1000 mL + 50 mL/ (kg over 10)
Fibromyalgia how many tender points needed
11 out of 18
Meningococcal vaccine schedule
11-12 yrs first dose, booster 16-18 *Age 16-18 years: 1 dose *adults: 1 dose MenACWY and revaccinate every 5 years if risk remains
Depo Provera is given every
11-13 wks as a shot
how much toddler usually sleep
11-14 hrs (involves 2-3 hrs of nap)
obese BMI pregnant mother: recommended total wt gain:
11-20 lbs
AFIB workup
12 lead, tsh (free T4), electrolytes, cbc w/ differentials, toxicity screening Consider 24hr holter if paroxysmal. Echocardiogram to r/o valvular pathology, which increases risk of stroke. D-dimer/ CT scan of chest PE protocol (if the pt has risk factors to merit a pulmonary embolism workup)
Babinski reflex disappears
12 months
Lexapro is not approved for children under...
12 y/o
MMRV vaccine schedule
12-15 mths, 4-6 yrs
Varicella schedule
12-15 mths, 4-6 yrs *dose 2 may be administered as early as 3 mths after dose 1 (However, the second dose of varicella vaccine does not need to be repeated if it was separated from the first dose by at least 4 wks.) *if no evidence immunity for adult, 2 doses separated by 4 wks *if received 1 dose, at least 4 wks after 1st dose
MMR vaccine schedule
12-15 mths, 4-6 yrs *if no evidence of immunity for age >=18, 1 dose *dose 2 may be administered as early as 4 wks after dose 1 *Unvaccinated children and adolescents: 2 doses at least 4 wks apart *MMRV max age limit: 12 yrs
all children younger than ______ years old should be restrained in the rear seats of vehicles for optimal protection
13 y/o
when is 2nd trimester?
14 0/7 - 27 6/7
afp is usually performed on what gestational weeks?
14th to 22 nd
Bupropion: how to initiate, maintenance, how to taper
150 mg PO QD x 3 days then 150 mg PO BID for 7-12 wks start 1 wk before the target quit date then continue for 7-12 wks If pt is successfully at quitting, consider ongoing maintenance therapy based on the individual pt risk or benefit. Efficacy of maintenance therapy (300 mg daily) has been demonstrated for up to 1 year. How to taper: Although discontinuation symptoms from bupropion are uncommon, nevertheless, we taper the drug over two weeks before stopping it. Taper to 150 mg PO QD before d/c. Pt must be monitored closely due to serious adverse neuropsychiatric events.
platelet normal range
150,000-400,000
adequate fluid intake: > 20 kg
1500 mL + 20 mL/ (kg over 20) *max 2400 mL/day
High risk HPV strains
16, 18 (31, 33) -70% of cervical cancer caused by 16 and 18
afp is most accurate during what gestational weeks?
16th to 18th week
NP can tx what degree of burns
1st and 2nd degree -3rd degree burn referred to physician (includes electrical burns, severe burns on the face, burns involving cartilage
Sulfonylurea list
1st gen: -chlorpropamide -tolbutamide -tolazamide 2nd gen: -glipizide (Glucotrol) -glyburide (Diabeta, Glynase) -glimepiride *chlorpropamide has the one of the longest duration (48 hrs) and is not used commonly in elderly or renally impaired d/t risk of hypoglycemia *most sensitive pts: developed T2DM after 40 y/o and had DM <5-10 yrs *Glynase is approved for gestational diabetes
uti tx -1st line -rest
1st line: - Bactrim/septra 160/800 mg tab PO BID for 3 days (17$) if pt has no renal failure - Nitrofurantoin 100 mg tab PO BID for 5 days (55$) if woman rest: Augmentin (pregnant), ceftriazone (septic), cipro (ambulatory pyelonephritis OR if bactrim didn't work)
outpatient pyelonephritis treatment
1st line: Cipro BID x 7 days
Balanitis treatment
1st line: Hygiene / saline wash BID 2nd line: Miconazole 2% BID or Clotrimazole 1% QD
androgenic alopecia male 1st line tx and alternative therapy
1st line: TOP Finasteride alternative: TOP Minoxidil (if pt wants to avoid systemic therapy) *not permanent solution, tx must continue or alopecia will recur
Tinea versicolor tx
1st line: TOP therapy - TOP antifungal (*Ketoconazole 2% shampoo*, Terbinafine) - TOP selenium sulfide (2.25% shampoo) - TOP zinc pyrithione (1% shampoo) systemic therapy is reserved for widespread or recurrent tinea versicolor or failed TOP therapy - Diflucan 300 mg PO two doses once a week for 2 weeks
Tinea Cruris Tx:
1st line: Topical antifungals - Terbinafine 1% CRM (Lamisil) 2nd line: systemic antifungal - Itraconazole 200 mg PO QD - Terbinafine 250 mg PO QD
tinea corporis treatment
1st line: topical antifungal - *Terbinafine and butenafine require shorter courses and lead to the most rapid response* - Topical terbinafine and all azoles have been shown to be safe and effective for tx of tinea corporis, cruris, and pedis. 2nd line: PO antifungal - Oral medications should be reserved for severe cases or when topical treatments have failed. - Oral itraconazole, fluconazole, and terbinafine are safe and effective for the treatment of tinea corporis, cruris, and pedis *tx should be continued for 1-2 wks after clinical clearning to prevent recurrence*
Tinea Pedis pharm tx
1st line: topical antifungal - Topical terbinafine, butenafine and all azoles have been shown to be safe and effective for tx of tinea corporis, cruris, and pedis (e.g. terbinafine 1% CRM (Lamisil) QD or BID for 4 weeks) - high cure rates have been obtained with terbinafine 1% cream applied to interdigital tinea pedis for one week 2nd line: PO antifungal (PO should be reserved for severe cases or when topical treatments have failed.) - PO itraconazole, fluconazole, and terbinafine are safe and effective for the treatment of tinea corporis, cruris, and pedis ●Terbinafine: 250 mg/day x 2 wks ●Itraconazole: 200 mg BID x 1 wk ●Fluconazole: 150 mg once weekly x 2 - 6 wks An alternative is griseofulvin, but this has been largely superseded by other antifungals. Itraconazole may also be used, but not in children. A broad-spectrum antibiotic may be needed in any secondary infection. *tx should be continued for 1-2 wks after clinical clearing to prevent recurrence*
raynaud phenomenon Tx:
1st lline: - CCBs (e.g., nifedipine, amlodipine), helps w/ vasodilation Surgery, cuts sympathetic nerve fiber
depression 1st line, 2nd line, 3rd line pharm
1st: SSRI 2nd: SNRI 3rd: TCA, 1st gen meds
HPV schedule
2 doses (9-14 y/o, 6-12 mths later) (minimum interval: 5 months; repeat dose if administered too soon) 3 doses (15-26 y/o, 1-2 mths later, 6 mths later) (minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 12 weeks / dose 1 to dose 3: 5 months; repeat dose if administered too soon)
Minipill has to be taken every day at same time within....
2 hrs
IPV schedule
2 months, 4 months, 6-18 months, 4-6 years
occasional strabisumus is a normal finding until age...
2 mths
Lymes serologic testing involves
2 tiered testing: EIA -> Western Blot (or EIA -> EIA) *If negative, no further testing needed *Western Blot can detect IgG or IgM AB *EIA detects AB against bacterium *Positive IgM results should be disregarded if the patient has been ill for more than 30 days. Two-tier serologic testing is recommended for non-EM presentations; synovial fluid when arthritis is suspected, and CSF analysis when neurologic involvement suspected.
posterior fontanel closes by
2 to 3 mths
full hypotensive efx from diuretic may not be noted until..
2 to 4 wks
after warfarin is disccontinued, anticoagulant efx persist for...
2 to 5 days
Depression follow up frequency
2 wks (phone), 4 6, 9, 12 (in-person) - check PHQ 9 - assess whether therapeutic changes are necessary. - total lack of response at 4 wks indicates a need for tx change - 1/3 will achieve remission after 12 wks - 80% pts experience recurrence, and 15% will be chronically ill
DTaP schedule
2, 4, 6, 15-18, 4-6 yrs minimum age for vaccine: 6 wks
PCV13: schedule
2, 4, 6, 12-15 months
PCV13 schedule
2, 4, 6, 12-15 months if missed sched and younger than 2 y/o, still get it if missed or incomplete sched and age between 24-59 mths, 1 dose 6-18. y/o w/ certain medical condition, 1 dose PCV then 1 dose PPSV23 8 wks after, if medical condition is something else than cochlear implant or CSF leak revaccinate w/ 2nd PPSV23 in 5 yrs 19 or older: 1 dose ppsv23, revaccinate w/ ppsv23 5 years after; if immunocompromised, give PCV13 then PPSV23 8 wks afterward 65 or older: give based on shared clinical decision making, then 1 dose PPSV23 1 yr after, (if + HIV, give PPSV23 8 wks after)
normal BMI pregnant mom: 1st trimester total wt gain
2-5 lbs
newborn weight
2.5 to 4 kg
PEDS emergent IV therapy IV: amt and bolus rate
20 ml/kg bolus isotonic fluid as rapidly as possible -over 10 to 15 minutes - Tx should be repeated as necessary, with monitoring of the patient's pulse strength, capillary refill time, mental status, and urine output. Stabilization often requires up to 60 mL per kg of fluid within an hour. - After resuscitation is completed and normal electrolyte levels are achieved, the patient should receive 100 mL per kg of ORT solution over four hours, then maintenance fluid and replacement of ongoing losses.
how long to breastfeed for per session
20 to 40 mins
Alkaline Phosphatase normal range
20-140 IU/L
25-hydroxyvitamin D normal range
20-50ng/mL
pregnant mom: limit caffeine to how much?
200 mg per day
HSV-2 recurrent episode: antiviral must be given within
24 hrs of lesion appearance or during prodrome
if baby doesn't walk by ______ mths old, be concerned
24 mths
routine obesity screening starts at what age
24 mths
Vitamin D deficiency tx
25(OH)D <12 ng/mL: one common approach is to treat with 50,000 IU (1250 mcg) of vitamin D2 or D3 PO once a week for 6 to 8 wks, and then 800 IU (20 mcg) of vit D3 daily thereafter. 25(OH)D levels of 12 -20 ng/mL , many clinicians supplement initially w/ 800 to 1000 IU (20 to 25 mcg) PO QD. 25(OH)D levels of 20 -30 ng/mL initial supplementation with D3 600 - 800 IU (15 to 20 mcg) PO QD may be sufficient. Infants and children: should receive at least 400 IU/ day from diet and supplements to prevent vitamin D deficiency (adults should receive at least 800 IU /day to redue fracture and fall rates) *F/U 25(OH)D measurements should be made approximately 3 to 4months after initiating maintenance therapy to confirm that the target level has been achieved.
Sildenafil dosing
25-100 mg (50 usual) one hour prior to sex. MAX once daily
when is 3rd trimester?
28 0/7 - 40 6/7 (or birth)
1st gen vs 2nd gen antihistamines
2nd gen are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st gen agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents
Cheilosis cause
2ndary infx w/ Candida albicans or bacteria staph a. multiple etiologies such as oversalivation, poorly fitting dentures, nutritional deficiencies, lupus, autoimmune disease, irritant dermatitis, squamous cell carcinoma, pacifier use in children
Mild Diarrhea def
3 or fewel stools per day
traveler's diarrhea def
3 or more unformed stools in 24 hours in a person from an industrialized nation traveling in a less developed country
roseola fever lasts about
3 to 5 days
until what age would you put tympanostomy
3 y/o
Skyla lasts
3 yrs
baby should be able to ride a tricycle by ...
3 yrs old (3 for tri)
Hand Foot Mouth Disease incubation period
3-5 days, but has been reported to range from 2-7 days
initial tx for highly motivated pt w/ Type 2 Diabetes and A1C near target:
3-6 mth trial of lifestyle modification before initiating pharmacologic therapy is reasonable
Ankle Sprain Grade II recovery time
3-6 wks to allow full return to sport
Subacute cough duration
3-8 weeks
hep b vaccine dosage
3-dose series Engerix B: 1 mL (20 mcg) IM at 0, 1, and 6 months Recombivax HB: 1 mL (10 mcg) IM at 0, 1, and 6 months Heplisav-B: Can be used as a substitute in a 3-dose series with a different hepatitis B vaccine Adults receiving dialysis or other immunocompromising conditions Recombivax HB (40 mcg/mL): 40 mcg IM at 0, 1, and 6 months, OR Engerix-B (20 mcg/mL): 40 mcg IM at 0, 1, and 6 months CDC ACIP guidelines recommends immunization with hepatitis B vaccine for all unvaccinated adults with diabetes mellitus through age 59 years. Vaccinate diabetics aged ≥60 yr at the discretion of the treating clinician.
pulse pressure range
30 to 50 mm Hg
aPTT normal range
30-40 secs
preterm
36 6/7 weeks
huntington disease patho
36+ CAG repeats in HTT gene leads to neuronal death in Basal Ganglia which lead to movement symptoms (chorea, athetosis) and mental symptoms (depression, dementia)
If you're carrying twins (and eating for three), the weight gain recommendations for women of an average weight is....
37 - 43 lbs
term baby
37-42 weeks
Surgical treatment of congenitally undescended testes is recommended as soon as possible after _________ mths of age.
4
at risk for Neural Tube defect mom should take at least how much folic acid?
4 mg daily (this is 10 times normal) start taking 4-5 mg daily 3 mths before conception and continuing until 12 wks post-conception
Rooting reflex disappears by
4 mths
Severe diarrhea def
4 or more stools per day WITH systemic symptoms (fever, chills, dehydration)
Moderate Diarrhea def
4 or more stools w/ local symptoms (abdominal cramps, nausea, tenesmus)
after cardioversion of afib, how much longer does pt need to be anticoagulated
4 wks
Ibuprofen dosage for Pediatric
4-10 mg/kg/dose every 6-8 hours
Monocyte role:
4-13% -circulates in serum, matures into macrophage upon entering organs - main scavenger cells of the immune system
A baby doubles birth weight by _____ ? Triples birth weight by _________?
4-6 mths, 12 mths
When to re-check to see if thyroid hormone therapy was adequate
4-6 wks
pregnant mom should take at least how much folic acid?
400 mcg daily
rheumatoid arthritis morning stiffness typically lasts
45 mins or longer
herpes medication must be given within
48 hourspe (acyclovir, etc)
Hospital acquired pneumonia presents after how long
48 hrs of inpatient stay
Bartholin gland is located in
5 and 7 oclock position of the vagina
Cephalosporin 1st gen vs later gens
5 gens in total -increases in spectrum (adds GN), but sometimes decreases in effectiveness towards GP -adds some lactamase resistance *all are generaly safe and effective and well tolerated but beware of c dif infx
PMDD diagnosis
5 or more symptoms, with at least one being affective symptom: 1. Markedly depressed mood 2. Marked anxiety 3. Marked affective lability 4. Persistent anger/irritability 5. hopelessness Must interfere with usual activities
Mirena lasts _______
5 years
meningitis vaccine protection duration
5 years
Liletta lasts
5 yrs
Esophageal spasm duration and cahracteristic
5-60 mins visceral, spontaneous, substernal, a/w cold liquids, relief w/ nitroglycerin
Naproxen dosage for Pediatric
5-7 mg/kg/dose every 8-12 hours (>2 y/o)
Finasteride class
5-alpha reductase inhibitor
PEDS mild dehydration administration amount and timing
50 ml/kg over 4 hrs using spoon, syringe, or medicine cup (1 mL/kg/every 5mins) + 10 ml/kg for every episode of loose stool or vomiting
roseola eyelid and lymphadenopathy frequency
50% eyelid swelling and posterior occipital lymphadenopathy
child length / height gain pattern in first year
50% increase by 12 mths
croup risk factors
6 mo-3 yo winter months M > F associated with ear infections and pneumonia family hx (3.2 times more likely)
breastfeeding can be used as contraceptive for
6 mths -pumping doesn't seem to have the same contraceptive benefits
persons starting ART should use another form of prevention w/ sexual partners for at least ______________
6 mths of tx and until an HIV RNA lvl of < 200 copies/ml has been documented
PTT normal range
60-70 secs
DEXA screening age
65 y/o in women w/o risk factors women w/ risk factors test at younger age (body wt <127 lbs, medical causes of bone loss, smoking, chronic alcohol use disorder, or rheumatoid arthritis)
ALT normal range
7-56 units/liter
average birth weight
7.5 lbs (3.4 kg)
# of diapers: 9-12 mth baby
8 diapers
small tympanic membrane perforation heals in
8 wks
# of diapers: 1-5 mth baby
8-10 diapers
lipid panel requires fasting for how long
8-12 hrs -12 hours recommended by authorities -the fast is recommended b/c of the influence of intake on cholesterol lvl. A normal diet for 7 days is recommended so that an accurate picture of the client's normal life is obtained.
Acne therapy takes how to?
8-12 wks to produce improvement
M-CHAT scoring
8-20 pts: high risk category 3-7 pts: medium risk for ASD -conduct a follow up interview. The interview includes a script to review all the failed items, ask for specific examples, and offer multiple examples against which to judge whether the child fails or passes the item. If the follow up- interview raises concerns, or if the child fails any 2 items on the follow-up, referral for comprehensive eval is warranted. 0-2 pts AND the provider/parents have no concerns: low risk; continue developmental surveillance at all subsequent health supervision visits
Random glucose level normal, prediabetic, diabetic
80-140 mg/dL : normal 140- 200 mg/dL: prediabetic > 200 mg/dL: diabetic
screen for developmental delay at what age
9, 18, and either 24 or 30 mths of age
Otitis Externa Common Pathogens
95% bacterial (Pseudomonoas Aeruginosa and Staph Aureus most common) Fungal (aspergillus, candida) Fungal is itchy!!
fasting blood glucose level normal, prediabetic, diabetic
< 100 mg/dL: Normal 100 mg/dL - 125 mg/dL: Prediabetes > 125 mg/dL: Diabetes
Gardasil schedule
< 15 y/o: 2 doses 6-12 mths apart >= 15 y/o: 3 doses 0, 1-2, 6 mths
low birth weight is..
< 2.5 kg (5 lbs 8 oz) - infants aborn too small; higher risk of cardiovascular disease, HTN, diabetes, stroke, etc
Maintaining HIV RNA lvl below _____________ w/ ART prevents HIV transmission to sexual partners
< 200 copies/ mL
If a child tests positive for Autism, who do you refer to for developmental intervention services
< 3 y/o: Early Intervention > 3 /yo: public school system
waist circumference range
< 40 inches around for men, < 35 inches for women
FENA result
<1% prerenal cause >2% renal or post renal cause
CRP normal range
<1.0 mg/L - lower risk: < 2 mg/L - higher risk > 2 mg/L
acute diarrhea length
<2 wks
Blood Alcohol Content Limit in California
>= 0.08% if the person is legal age. >= 0.04% for commercial vehicle drivers >= 0.01% if the person is under 21 years old. OR if the person (of any age) is on a DUI probation
Endometriosis clinical manifestations
A significant number of women remain asymptomatic, and most women have a normal pelvic exam. *chronic pelvic pain* cramps with period *infertility* dyspareunia (painful sex) irregular bleeding backache painful bowel movements dysuria diarrhea/ constipation symptoms may or may not line up with menstrual cycle, but with menopause when estrogen is no longer produced, symptoms may disappear ovarian cysts "chocolate cysts" -rupture causes acute pain and irritation that promotes adhesion formation-> may obstruct bowel, uterus, fallopian tubes, and ovaries
Narcolepsy def
A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep (also called Sleep Onset REM Periods = SOREMP), often at inopportune times. *Sleep onset REM periods (SOREMPs) are REM sleep periods that occur within 15 minutes of sleep onset. SOREMPs are considered to support the diagnosis of narcolepsy.
Ethnic populations at risk for possible Hypertension
AA -Asians are at lower risk
when start calculating BMI
AAP- start at 24 mths (before 2 y/o, use length for weight???)
Screen for autism at what ages?
AAP: 18 and 24 mths
when would you screen for ASD in children w/o clinical ASD features
AAP: in primary care, all children in 18th and 24th mth - use M-CHAT
Mongolian spots typically fade by...
AAP: most Mongolian spots typically fade by 5 yrs old. Some may persist for life.
HIV ELISA test detects...
AB against HIV which are typically produced between 2 and 12 wks after infx
TIA screening tool <Stroke, transient ischemic attack, TIA>
ABCD2 Scoring System for Early Prediction of Stroke - Age > 60 yrs (1 pt) - BP > 140/90 (1 pt) - Clinical features of unilateral weaknesses w/ or w/o impaired speech (2 pts) OR speech impairment w/o unilateral weakness (1 pt) - Duration up to or > 60 mins (2 pts) or 10-59 mins (1 pt) - Diabetes (1 pt) *Higher the score, the greater the risk Result: - Low score (1-3 score): no hospitalization unless pt has afib - moderate (4-5) or high score (6-7): hospitalize and monitor for ONE DAY
HTN cause mneumonic
ABCDE Apnea, Aldosteronism Bruits (in renal artery - renal artery stenosis) Bad kidneys (renal parenchymal disease) Catecholamine (excess), Coarctation of the aorta, Cushing's syndrome, Drugs, Diet Erythropoietin (excess) Endocrine disorders
febrile seizure tx
ABCs, cool with tepid (room temp) water. Cool until PT begins to shiver. Transport. pharm: only phenobarbital and valproic acid ahve demonstrated efficacy in preventing febrile seizure; Diazepam may be given when seizure is prolonged but will sedate a child and possibly complicate the evaluation for a source of the fever (buccal midazolam is an alterantive when IV access is unavailable)
Gestational Diabetes screening
ACOG- 50g of oral glucose challenge test (non-fasting) @ 24-28 wks gestation: 50g of glucose followed by a blood sugar in 1 hr (>130 is positive) -if positive, perform 100 g 3 hr OGTT (the diagnostic test for gestational diabetes) - those with normal glucose should be reassessed every 3 yrs - those with pre-diabetes should be assessed annually
Fibromyalgia Dx:
ACR 2010 Criteria: 1. Widespread Pain Index (WPI) >= 7 and symptom severity (SS) scale >= 5 or WPI 3 -6 and SS scale >= 9 2. duration >= 3 mths 3. Ruled out other conditions (keep testing to minimum: CBC, ESR, CRP, CK, TSH, sleep, mood eval, neuro) *WPI = # of painful body areas from a defined list of 19 areas (final score: 0-19) *SS score (final score: 0-12) includes an estimate of the degree of fatigue, waking unrefreshed, and cognitive symptoms, and numbers of somatic symptoms in general (pain or cramps in lower abdomen, depression, headache) over the past week.
pregestational diabetes - hypoglycemic of choice
ADA consensus statement advises discontinuation of PO hypoglycemics and intiation of insulin ASAP, except 1st trimester since metabolic control may be disrupted durin the transition. Women with type 2 diabetes who have good glycemic control with medical nutritional therapy alone can remain on this therapy during pregnancy while closely monitoring glucose levels
Ivabradine contraindications
ADHF, BP < 90/50 mmHg, sick sinus syndrome, SA block, pacemaker, resting HR <75 bpm, severe hepatic impairment, afib
traveler's diarrhea pediatric tx
AFP: PO Hydration most important > 1 mth old - Azithromycin tx of choice (Fluoroquinolones are not approved by the U.S. Food and Drug Administration (FDA) for use in children, and rifaximin is approved only for children 12 years and older). AFP: Loperamide is approved for children older than two years, but should not be used in children with dysentery. AFP: Loperamide (FDA pregnancy category B) may be used, but bismuth subsalicylate (FDA pregnancy category D) should be avoided.
when to screen for ASD?
ALL children should receive a formalized ASD screening at their 18- and 24-month well-child visits: The American Academy of Pediatrics (AAP) recommends screening all children for ASD at the 18 and 24-month well-child visits in addition to regular developmental surveillance and screening
which is more specific to liver (AST or ALT)?
ALT (thus AST/ALT ratio will be low in most types of liver disease)
Lead poisoning symptoms
AMS (altered mental status), irritability, lethargy, anorexia, vomiting, diarrhea, abdominal pain, anemia (microcytic), HTN can concurrently present w/ iron deficiency anemia
Excedrin is composed of...
ASA Acetaminophen Caffeine
HiB schedule
ActHIB, Hiberix, or Pentacel 4 doses: 2, 4, 6, 12-15 mths PedvaxHIB 3 doses: 2, 4, 12-15 mths *Pentacel protects against DTaP, polio, HiB. Other brands protect against just HiB
Mallory-Weiss Syndrome s/s
Acute onset Hematemesis (either red blood or coffee-ground emesis) Epigastric pain or pain in the back Patients often have a history of nonbloody emesis, retching, or coughing prior to hematemesis Patients with significant bleeding may have signs of hypovolemia and hemodynamic instability (eg, resting tachycardia, hypotension)
Synthetic Mineralocorticoid is used in what two conditions usually?
Addison's Disease & Severe Congenital Adrenal Hyperplasia
Metformin how to increase dosage
Adults: Increase dose by 500 mg a week or 850 mg every two weeks Children: - increase daily dose by 500 mg at weekly interval
measles: transmission method
Airborne (can live on air or surface for up to 2 hrs) and contact
Synthetic Mineralocorticoid mimics what hormone
Aldosterone
major natural mineralocorticoid in humans is
Aldosterone
PPSV23 is recommended for what people
All adults 65 yrs or older - give 1 yr after PCV13, unless immunocompromised (8 wks after PCV13) anyone 2 yrs or older w/ certain medical conditions that can lead to an increased risk for pneumococal disease high risk: - chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure) - chronic lung diseaes (including asthma tx'ed w/ high dose, oral corticosteroids) - diabetes - cerebrospinal fluid leak - cochlear implant - SCD and other hemoglobinophaties - anaatmic or functional asplenia - congenital or acquired immunodeficiency - HIV infx - chronic renal failure - nephrotic syndrome - malignant neoplasms - leukemias - lymphomas - hodgkin diseaes - other diseases a/w tx w/ immunosuppressive drugs or radiation therapy - solid organ transplantation - multiple myeloma - chronic liver disease - alcoholism
secondary prevention examples
All screening tests and lab tests (e.g., mammography, Pap smears) are secondary prevention activities. *purpose is to detect disease at an early stage to halt or slow its progress
allergy shot vs food
Allergy shots aren't currently recommended for food allergies.
Gout Prevention: drug of choice
Allopurinol 100 mg PO QD (if pt has normal renal function)
Antacid AE's:
Aluminum based: constipation Magnesium based: diarrhea
Antacid examples
Aluminum hydroxide gel (Amphojel), Magnesium Hydroxide (Milk of Magnesia), Maalox - contains both aluminum and magnesium Tums (Sucrose + Calcium Carbonate)
IE vs endocarditis prophylaxis standard regimen
Amoxicillin 2 g PO x 1 dose (adults) Amoxicillin 50 mg/kg 1 hr before procedure x 1 dose (peds) PCN allergy- Clindamycin 600 mg or Clarithromycin 500 mg or Keflex 2 gram
Infective Endocarditis prophlyaxis abx of choice
Amoxicillin typically used - Cephalosporin or vanco if concerns for resistance
ESR vs CRP
An ESR and a CRP are similar in cost. *ESR*: An indirect measurement of fibrinogen elevation is better studied and is more widely used, slow to rise *CRP* : Peaks in 48 hrs. Direct quantification of an acute phase response may actually be the more useful of the two in the diagnosis and management of inflammatory conditions. More specific, elevates quickly. Is less suitable and less preferable to assess inflammation older than 2 days
Adrenal crisis
An acute, life-threatening state of profound adrenocortical insufficiency requiring immediate medical management. It is characterized by glucocorticoid deficiency, a drop in extracellular fluid volume, hyponatremia, and hyperkalemia. Severe ABD pain, profound weakness, hypotension, renal failure, shock, and possibly death. May result from stress/trauma, or from abrupt discontinuation of long-term steroid medication use, ex: Prednisone.
Mesenteric ischemia
An interruption of the blood supply to the mesentery.
Inflammatory Bowel Disease vs Anemia
Anemia is a common extraintestinal manifestation of IBD and is frequently overlooked as a complication. Pts w/ IBD are commonly found to have iron deficiency anemia (IDA) secondary to chronic blood loss, and impaired iron absorption due to tissue inflammation.
CAD signs and symptoms
Anginal pain SoB Diaphoresis Pallor Belching, nausea, indigestion Dizziness, light headedness, clamminess Fatigue *Pts w/ diabetes - discomfortless ischemia (silent ischemia, sympathetic dysfunction and absence of chest discomfort due to failure of transmission of neural impulses from heart to spinal cord) *SILENT ISCHEMIA IS MUCH MORE COMMON THAN SYMPTOMATIC
Resolved Hepatitis A serology
Anti HAV IgM: negative Anti HAV IgG: positive (immunity d/t infx or vaccine)
Active Hepatitis A serology
Anti HAV IgM: positive Anti HAV IgG: positive/negative (can be detected 8-12 wks after HAV infx and remains positive)
Hepaititis B Immunity serology
Anti-HBs: positive Anti-HBc: positive if immunity due to an infx
Acute Bacterial Rhinosinusitis treatment
Antibiotics should be reserved for symptoms that persist >10 days First line amoxicillin 500 mg PO TID or 875 mg PO BID x 5-7 days OR Augmentin 500/125 mg PO TID or 875/125 mg PO BID x 5-7 days - Augmentin preferred if PCN allergy -Doxycyline 100 mg PO BID or 200 mg PO QD
Sinusitis first line abx
Augmentin- b/c of its safety and efficacy
Folate Deficiency Anemia tx
B9 1 mg PO QD until the deficiency is corrected
BZD vs peds
BZD is safe in childsren
Bacterial Vaginosis Tx for male partner
Bacterial Vaginosis is not an STD-> male partner does not need tx *male rarely carries this infx
The most prevalent cause of vaginal discharge is...
Bacterial vaginosis
positive amine would indicate...
Bacterial vaginosis (part of Amsel criteria) - Positive test: sensitivity, 67%; specificity, 93% trichomoniasis - Positive test: sensitivity, 67%; specificity, 65%
fluoroquinolone moa
Bacteriocidal - inhibit bacterial DNA topoisomerase and DNA gyrase
huntington dx
Based upon presence of the typical clinical features, a family hx of the disease (if known), and genetic confirmation of the CAG expansion If suspected, refer you to a neurologist for diagnosis and tx. Neuroimaging no longer used in confirming dx of HD
osteoporosis tx
Bisphosphonates first line - Fosamax (Alendronate) 5 -10 mg QD or 70 wkly -Actonel (risedronate) 5 mg daily or 35 mg wkly ( or 150 mg tab Q mth) Calcium 1200 mg + Vitamin D 800 IU/day selective estrogen receptor modulator (SERM) Wt bearing exercises (walking, jogging, aerobic dance classes, most sports, yoga, taichi)
Chronic Pancreatitis lab markers
Blood glucose Fecal Fat
chadwick's sign
Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion.
when to initiate abx in diarrhea in pediatric
BoardVitals: if systematically ill, immunocompromised, or very young UpToDate: Abx should not be used routinely for well-appearing children with acute bloody diarrhea unless a specific pathogen has been isolated. Antibiotic therapy may be a risk factor for the development of HUS in patients with bloody diarrhea due to E. coli O157:H7, which may be indistinguishable from bloody diarrhea seen with other non-E. coli bacterial etiologies
Fibromyalgia vs myofascial pain syndrome
Both associated with middle aged women, with psychological comorbidities. Myofascial pain syndrome has <11/18 of the possible sites of pain. it is more LOCALIZED Avoid narcotics for both! Antidepressants and PT work best
Bactrim Spectrum of activity
Broad spectrum, covering Gram + (MRSA) and Gram - (pseudomonas)
Symbicort is composed of
Budesonide + Formoterol
Bisphosphonate pregnancy category
C -animal studies have demonstrated that they can cross the placenta and are a/w anatomic changes
alopecia workup
CBC- iron deficiency anemia zinc- zinc deficiency thyroid- thyroid
Tic Disorder management
CBT Habit reversal training Reducing anxiety Medication - Antipsychotic (Halodol & Risperidone) - Epilepsy meds - ADHD meds
Panic Attack first line tx
CBT then combo CBT and SSRI (or SNRI)- this is most effective
insomnia Rx
CBT for insomnia (CBT-I) is preferred as first-line therapy for chronic insomnia in most patients Controlled-release melatonin and doxepin are recommended as first-line agents in older adults the so-called z-drugs (zolpidem, eszopiclone, and zaleplon) should be reserved for use if the first-line agents are ineffective. For the general population with difficulty falling asleep, controlled-release melatonin and the z-drugs can be considered. For those who have difficulty staying asleep, low-dose doxepin and the z-drugs should be considered. Short-term: -melatonin agonist- Ramelteon (a/w improvement in sleep onset) - Benzos - GABA agonist (Benzo-like drugs)(can take if pregnant), Eszopiclone (Lunesta)- fall and stay asleep, Zolpidem (Ambien)- fall and stay sleep (not approved for long term use), Zaleplon (Sonata)- fall asleep - melatonin (OTC, it is not recommended as a tx for insomnia in most pts except when sleep disturbances are due to delayed sleep-wake phase syndrome or in pts w/ low level of endogenous melatonin, such as in aging; should be used for short term for 3 mths or less) Long-term: - GABA agonist - Ramelteon (Rozeram)- melatonin agonist - trazadone Antidepressant - Doxepin - Trazodone (IF comorbid depression noted) *Benzo-like drugs have no active metabolites and have fewer DI's than BZDs *all have risk of dizziness and drowsiness,potentiated by alcohol and CNS depressants
CGM advantage <continuous glucose monitoring>
CGMs lowered hgbA1C anywhere from 0.3 to 1 % when compared to traditional fingerstick glucose checks may reduce the risks of hypoglycemia help clarify the effx of diet and exercise on blood sugar lvls can set alarm to alert them when glucose lvls are too low or too high CGMs can show early morning spikes or dips in blood glucose at times when most people aren't checking sugars frequently.
CHA2DS2-VASc indication
CHA2DS2-VASc score is one of several risk stratification schema that can help determine the 1 year risk of an ischemic stroke in a non-anticoagulated patient with non-valvular AF.
COPD epidemiology
COPD is 3rd leading cause of death in the US: almost 140,000 deaths annually Established risk factors: age, male gender, cigarette smoking, reduced llung function, occupational exposures, air pollution, alpha1-antitrypsin phenotypes Probable risk factors: respiratory tract infections, allergic conditions, bronchial reactivity, climate, poor socioeconomic resources, alcohol intake, poor diet, ABO, ABH secretor, cell phenotypes, impaired immune fucntion, familial factors
Kawasaki Classic symptoms
CRASH and BURN (fever) Conjunctivitis (spares limbus) Rash ~ all over body parts (that are initially polymorphorous then desquamate) Adenopathy Strawberry Tongue Hands and feelt swollen w/ rash High fever- 5 or more days that typically doesn't resolve with antipyretics
CVA workup <stroke, transient ischemic attack, TIA>
CT- noncontrast scan of head ECG CXR pulse Ox/ABG CBC w/ plts PT/INR PTT glucose CRE/BUN electrolyte EEG CSF Carotid US ESR/CRP Phospholipid holter monitor NIHSS Stroke scale assessment ABCD2 (if pt had TIA)
Concussion imaging tools
CT: study of choice for eval of ACUTE head injury MRI: study of choice for pts who have prolonged symptoms (>7 days) or when a new change occurs in an individual's neurological signs or symptoms
Major advantages of minipill over COC
Can be taken if pt is following: - high risk of heart disease, blood clots, HTN, migraines - older than 35 - smoker - overweight
Aphthous stomatitis healing time
Canker sores may hurt for 7 to 10 days. Minor canker sores heal completely in 1 to 3 weeks, but major canker sores can take up to 6 weeks to heal. Some people get another canker sore after the first sore has healed. Most canker sores heal without a scar.
Goodell's sign
Cervical softening *vaginal wall will cave in between speculum during speculum exam
Irritable Bowel Syndrome tx <IBS tx, IBS management>
Check allergy - do allergy testing if indicated Diet modification - Avoid certain foods such as those w/ short-chain carb - Avoid FODMAP For constipation - Soluble fiber - Stool softeners - Osmotic laxatives For spasms and pains - Anti-diarrheal (loperamide effective at decreasing stool frequency and increasing stool consistency) - Anti-muscarinic Psychosocial management - stress - anxiety - depression *Exercise - 3-5 times per week *Probiotics - *Evidence supporting the use of probiotic for IBS is weak but may show a significant benefit for reducing IBS symptoms and decreasing pain and flatulence - no differences noted among Lactobacillus, Streptococcus, Bifidobacterium, and probiotic combination Abx - should not be routinely recommended in all patients with IBS - we suggest a two-week trial of rifaximin. Antispasmodics - commonly used: hyoscyamine (Levsin), dicyclomine (Bentyl) - administer PRN or in anticipation of stressors - is short term relief antidepressants, psychological tx, and peppermint oil may improve IBS symptoms
Chvostek's sign
Cheek, facial spasm when Cheek is tapped associates with hypocalcemia
CHIP
Children's Health Insurance Program - healthcare program administered through the Centers for Medicare and Medicaid Services - covers more children than Medicaid but has a fee
Pregnancy vs Malaria prophylaxis
Chloroquine sensitive areas: - Chloroquine Chloroquine resistant areas: - Mefloquine Wear 20% minimum DEET insect repellent at all time and avoid all mosquito bites. *Doxycycline contraindicated b/c of teratogenic effx on the fetus after the 4th mth of pregnancy (12th wk gestation and on) *If possible, delay travel to malaria prevalent areas. * Make appt w/ doctor for pretravel care at least 4-6 wks before pt leave.
Malaria tx
Chloroquine, mefloquine, atovaquone/proguanil (for blood schizont), primaquine (for liver hypnozoite)
Chlorthalidone vs HCTZ
Chlorthalidone is longer acting and more "effective" than HCTZ. Preferred by JNC 8
Alzheimer tx
Cholinesterase inhibitor (mild-moderate) - donepezil (Aricept) approved for all stages - rivastigmine (Exelon) all stages - galantamine(Razadyne) mild to moderate stages Memantine (NMDA receptor antagonist): moderate- severe stages *both can be combined but cholinesterase inhibitor monotherapy is still equally effective
Narcolepsy ddx
Chronic daytime sleepiness (insufficient sleep, OSA, central sleep apnea, periodic limb movements, circadian rhythm sleep-wake disorders, mood disorders, idiopathic hypersomnia) Hypnagogic hallucinations and sleep paralysis Cataplexy
chronic bronchitis cause
Cigarette smoking (90%) Repeated -airway infections Genetic predisposition Inhalation of physical or chemical irritants
Fluoroquinolone list
Ciprofloxacin Levofloxacin (Levaquin) Moxifloxacin
Cipro HC is composed of
Cirpofloxacin and Hydrocortisone
nuclear sclerosis def
Cloudiness, hardening, and yellowing of the central region of the lens in the eye called the nucleus. * Commonly confused with cataracts but is different in both the cause and effect on the patient. ... In contrast to cataract, nuclear sclerosis is not considered to cause vision deficits. However, it can cause a visible cloudiness to the lens that can be confused with cataracts
gram positive bacteria list
Cocci -Staphylococcus (catalase +) 1. staphylococcus aureus (coagulase +) 2. Staph epidermis (coagulase -) 3. Staph sapophyticus (coagulase -) -Streptococcus (catalase -) 4. Strep pyogenes (b-hemolytic) 5. Strep agalactiae (b-hemolytic) 6. Enterococcus faecalis (y-hemolytic) 7. Enterococcus faecium (y-hemolytic) 8. Strep pneumoniae (a-hemolytic) 9. Strep viridans (a-hemolytic) Bacilli 10. Corynebacterium 11. clostridium 12. Listeria 13. Bacilus
Gout: drug of choice in pts being anticoagulated
Colchicine 0.6 mg PO TID a day until pain lessens then 0.6 mg PO QD or BID until complete resolution + 2 days *Colchicine dosage is lowered d/t GI SE (N/V/D)
SABA/SAMA Combo list
Combivent (albuterol and ipratropium) take w/ Respimat Duoneb (albuterol and ipratropium) take w/ nebulizer
Fifth's disease tx
Comfort measures no vaccine available
Hand Foot Mouth Disease epidemiology
Common in children younger than 5 yrs, but can affect older children and adults Most common in late summer and fall
Spironolactone MOA
Competitive inhibition for aldosterone receptors in distal tubules, leading to increased excretion of fluid and sodium with increased potassium retention also is androgen receptor antagonist - first line tx addition for hirsutism in pts already on combined PO contraceptive
CVA mimics, ddx <stroke mimics, stroke ddx>
Complicated Migraine - Preceding aura -> strange light or smell - hx previous migraines Seizures - postictal period -> weakness on one side of the body - Todd's paralysis Brain tumors - gradual progression of symptoms - also can have seizures
Crohn's vs UC: which is more common in peds?
Crohn's
which inflammatory bowel disease has skip lesion?
Crohn's
Vitamin B12 Deficiency tx
Cyanocobalamin 1000 mcg SC/IM QD x 7 days, then wkly x 4 mths, then mthly for the rest of the pt's life PO (for mild to moderate symptoms): 1000-2000 mcg PO QD on empty stomach
Misoprostol brand
Cytotec
Vitamin D2 vs D3 difference, and which would you recommend
D2 (ergocalciferol) is less potent and has a shorter duration of action than D3 (Cholecalciferol). D2 is also indicated for rickets, hypoparathyroidism, and familial hypophophatemia, D3 is indicated for dietary supplement Recommend D3, most of the time
DRE: sensitivity
DRE has low sensitivity and specificity for detecting prostate cancer. In one meta-analysis, DRE performed by primary care clinicians had an estimated sensitivity of 51 percent, a specificity of 59 percent, and a calculated overall positive predictive value (PPV) of 41 percent The low sensitivity is due in part to the fact that DRE only detects palpable abnormalities in the posterior and lateral aspects of the prostate gland.
Dementia dx
DSM-5: evidence from the hx and PE that indicates significant cognitive impairment in at least one of the following cognitive domains: • Learning and memory • Language • Executive function • Complex attention • Perceptual-motor function • Social cognition - The impairment must be acquired and represent a significant decline from a previous level of functioning - The cognitive deficits must interfere with independence in everyday activities - The disturbances are not occurring exclusively during the course of delirium - The disturbances are not better accounted for by another mental disorder (eg, major depressive disorder, schizophrenia) All pts suspected of Alzheimer should undergo neuroimaging. MRI can demonstrate hippocampal and cortical atrophy in temporal and lateral parietal lobes consistent w/ Alzheimer. DSM-4-TR was widely used: progressive impairment in ≥2 areas of memory, executive function, attention, language, or visuospatial skills and significant interference in ability to function in work, home, or social interactions
Glaucoma Pharm tx
Decrease production of aqueous humor - Beta-adrenergic receptor antagonist - Carbonic anhydrase inhibitors Increase outflow of aqueous humor - Prostaglandin analogs (Misoprostol) Decrease production and increase outflow
Kussmaul's sign
Deep and rapid breathing pattern occur in patients with diabetic ketoacidosis, metabolic acidosis, kidney failure
Drusen bodies
Deposits in Bruch's membrane that lead to degenerative changes of the macula
Actinic Keratosis Tx
Dermatology referral Most common: Cryotherapy using Liquid Nitrogen (suggested for few isolated AK's) Laser therapy available Curettage: another surgical procedure Imiquimod Cream (Aldara): particular effective when there are multiple lesions (moa: stimulates immune system to recognize these precancerous lesions and attack them)
onychomycosis tx
Dermatophyte: PO Terbinafine 250 mg PO QD - PO itraconazole is an alternative treatment for patients who cannot tolerate terbinafine or for patients who fail to respond to terbinafine. Nondermatophyte / Candidal: PO Itraconazole - PO terbinafine may also be effective for some patients Duration: Fingernails x 6 weeks Toenails x 12 weeks *must confirm dx prior to prescription (KOH preparation provides almost immediate results) *recurrence is common
fluoroquinolone vs pediatric
Despite restricted FDA-approved pediatric indications, fluoroquinolones have been used off-label to treat a variety of infections in children due to their broad spectrum of activity, tolerability, high bioavailability, and easy oral dosing. Routine use of systemic fluoroquinolones should be avoided in children due to the potential risk of musculoskeletal toxicity. However, it is reasonable to use a systemic fluoroquinolone in children when no safe or effective alternative exists or when parenteral therapy can be avoided by using an oral fluoroquinolone. This approach is consistent with recommendations from the *American Academy of Pediatrics*
Glasgow Coma Scale scoring and results
E4 V5 M6 Eyes: 4-spontaneous 3-verbal 2-pain 1-no response Verbal: 5-oriented 4-confused 3-inappropriated words 2-incomprehensible sounds 1-no response Motor: 6-obeys command 5-localizes pain 4-withdraws from pain 3- flexion response to pain 2- extension response to pain 1-no motor response Severe: GCS 8 or less Moderate: GCS 9-12 Mild: GCS 13-15
HFrEF symptoms
EF <= 40% clinical manifestations of HFpEF are same as those for HF generally, including HFrEF Dyspnea PND Orthopnea Fatigue Physical signs (elevated jugular venous pressure, pulmonary rales, and lower extremity edema) may or may not be present *S3 Gallop* Mitral Regurgitation (may improve if excess fluid is fixed) Pleural effusion *bibasilar crackles in the lung* Cheyne stokes respiration Abdominal pain Anorexia Nausea Bloating Tachycardia Cough Hemoptysis
HFpEF symptoms
EF >=50% clinical manifestations of HFpEF are same as those for HF generally, including HFrEF Dyspnea PND Orthopnea Fatigue Physical signs (elevated jugular venous pressure, pulmonary rales, and lower extremity edema) may or may not be present S3 Gallop Mitral Regurgitation (may improve if excess fluid is fixed) Pleural effusion Cheyne stokes respiration Abdominal pain Anorexia Nausea Bloating Tachycardia Cough Hemoptysis *muscles of the heart contract normally but may be thicker causing the ventricle to hold an abnormally small volume of bblood *HFpEF is more common in women, with increasing age, and hypertensive pts
Parkinson's disease tx
Early specialty referral (neurology) for patients with suspected PD to receive a more thorough clinical assessment and for treatment recommendations If sxs minimal, typically do not need any antiparkinson therapy if sxs do not interefere w/ quality of life - MAOI inhibitor is 1st line for minimial sxs (Selegiline) - Amantadine (antiviral) monotherapy is an alternative, particularly for those w/ predominant tremor. Moderate sxs - < 65 y/o: either carbidopa-levedopa or dopamine agonist (compared to levodopa, DA's produce more frequent SE (somnolence, peripheral edema, nausea, dizziness, impulse control disorder)) (levodopa is more effective than than DA for reduction of motor symptoms but more frequently produces dyskinesia (often involves hyperkinetic movements, including chorea, dystonia, and athetosis.) than DA, especially in younger pts) If > 65 y/o: - Carbidopa-levodopa first line (Dopamine agonists are not well tolerated in older population) Pharm list: 1. levodopa + Carbidopa (doesn't get metabolized before BBB) 2. Amantadine (antiviral that increases dopamine production) 3. Dopamine agonist (tricks brain to think there's more dopamine; DA's are not well tolerated in elderly) - Bromocriptine - pramipexole - ropinirole 4. COMT inhibitor (inhibits COMT which degrades dopamine and levodopa 5. Selegiline (MAO-B inhibitor, inhibits degradation of Dopamine) 6. Anticholinergic (Benztropine)- helps w/ tremor by decreasing amount of acetylcholine which in turn increases dopamine lvl
pulmonary HTN dx:
Echo -shows increased pressure in pulmonary arteries and right ventricle -then follow up tests done to identify the underlying cause
sore breast in first 2 weeks: recommendation
Educate the mother that this is normal during the first week or 2 of breastfeeding and the soreness will eventually go away -Nursing during the first 2 weeks after delivery may cause tenderness and soreness of the nipples and usually resolves after this. The mother should continue to breastfeed as she has been advised, and she should make sure the infant is latching on appropriately.
Nipple Pain best education for breastfeeding mothers
Education on proper positioning and attachment of the infant
Entresto benefit vs HF
Entresto w/ BB and aldosterone antagonists is recommended to reduce mortality/morbidity (Class I/A) *can be used instead of ACEi or ARB
Macrolides list
Erythromycin (Erythrocin) azithromycin (Zithromax) clarithromycin (Biaxin)
estrogen is contraindicated during breastfeeding, b/c
Estrogen-containing contraceptives have been linked to low milk supply and a shorter duration of breastfeeding even when started when baby is older, after milk supply is well established.
Nexplanon active component
Etonogestrel (Progestin)
Roseola aka
Exanthem Subitum/ Sixth disease
Most common causes of Cushing
Exogenous cushing (aka iatrogenic cushing) -too much outside source of cortisol-like substance Ectopic ACTH syndrome - 1% of small cell lung carcinoma have ectopic ACTH syndrome Pituitary adenoma - secretes excess ACTH Adrenal tumors *All other causes of cushing's syndrome are extremely rare
Nexplanon lasts _________
FDA approved for 3 yrs
FDA Category N
FDA has not classified the drug
D-Dimer normal range
FEU: <500 ng/mL (more commonly used) or DDU: <200 ng/mL
Roseola complication
Febrile seizure (b/c temp will spike extremely high in short time)
Iron deficiency: iron is generally given until...
Ferritin and TSAT normalize *important to note Ferritin is an acute phase reactant and may be chronically elevated in individuals w/ concomitant inflammatory processes even when iron stores are low.
Nexplanon how long does it take for the birth control to work
First 5 days of period, protected right away any other times, use condom for 7 days
Peptic Ulcer Disease tx
First line: - Acid suppression: PPI (min 4 wks for duodenal ulcer, 8 wks for gastric ulcer) - NSAID-induced ulcer- discontinue use; Treat with PPIs for 4-8 weeks - H. pylori-induced ulcers: triple abx therapy (clarithromycin, amoxicillin, and a PPI if no PCN allergy)
C Diff Diarrhea tx
First line: Vancomycin 125 mg PO QID x 10 days Fidaxomicin 200 mg PO BID x 10 days Second line: PO Metronidazole
trigger finger injection tx
First thing to do: - activity modification (continue normal activity but avoid aggravating movement such as pinching or grasping of the fingers) - short term PO NSAID - if mild: suggest taping the affected finger w/ the adjacent normal finger to limit flexion of the finger - if moderate to severe: splint at slight flexion to immobilize joint (to alleviate pain and reduce triggering) can be worn as mcuh as possible generally to 3 to 6 wks mainstay tx: Tiramciolone/methypredinosolone injection mixed w/ lidocaine if s/s not resolved after 4-6 wks of conservative therapy -may be repeated in 6 wks if s/s not improved by at leas t50 % - maximum 3 injections
Community Acquired Pneumonia tx
Following are tx for outpatient CAP. Previously healthy, no abx in past 3 months: - a macrolide (e.g. azithromycin 500 mg PO 1 time and then 250 mg PO daily for 4 days) - alternative: doxycycline 100 mg PO BID for 10 days Comorbid conditions, immunosuppressed, antibiotic use in past 3 months: - Levofloxacin 750 mg PO daily for 5 days; or moxifloxacin 400 mg PO daily for 5 days; or - alternative: Amoxicillin 1 g PO TID; amoxicillin-clavulanate 2 g PO BID + macrolide/doxycycline for 5 days - Tx may be stopped if Afebrile for >48 hours, Supplemental oxygen no longer needed, No more than one of the following (HR >100 beats/min, RR >24 breaths/min, Systolic blood pressure (BP) ≤90 mm Hg) Antibiotic treatment in preschool-age children is not routinely required because viral pathogens are more common. - Presumed typical bacterial pneumonia (Amoxicillin-clavulanate 90 mg/kg/day PO BID (max 4 g/day) - Presumed atypical bacterial pneumonia (Azithromycin 10 mg/kg PO on day 1 (max 500 mg) and then 5 mg/kg/day (max 250 mg) on days 2 to 5)
IE: empiric abx therapy guideline
For patients with suspected IE who present without acute symptoms, empiric therapy is not always necessary, and can be deferred until blood culture results are available, particularly since accurate microbiologic diagnosis is a critical first step in planning the treatment strategy. For acutely ill patients with signs and symptoms strongly suggestive of IE, empiric therapy may be necessary. Such empiric therapy should be administered only after at least two (preferably three) sets of blood cultures have been obtained from separate venipunctures and ideally spaced over 30 to 60 minutes.
Free T4 vs Total T4 vs T3
Free T4 more accurately reflects how the thyroid gland is functioning when checked w/ a TSH TT4- can change when binding proteins differ T3- useful for HYPERTHYROIDISM and rarely useful for hypothyroidism (b/c it is the last test to become abnormal) * Pt can become severely hypothyroid w/ a high TSH and low FT4 but have normal T3 * Amount of transport protein can change, changing how much bound T4 and T3 is measured. This happens frequently and with the use of birth control pills.
CCB side effects
Gingival hyperplasia, Constipation, *Edema* Headache, Flushing, Dizziness, Cardiac depression
Rheumatoid Arthritis treatment
Goal of tx: reduce inflammation and pain, promote joint function, and prevent joint destruction and deformity Pharmacological management: -NSAIDs to reduce inflammation and pain -Corticosteroid meds may be desirable during severe flare-ups or when the patient's condition is not responding to NSAIDs Disease-modifying anti-rheumatic meds are slow-acting and take weeks or months to become effective, however, they have the ability to slow the progression of joint destruction and deformity PT interventions include passive and active ROM, heating and cooling agents, splinting, patient education, energy conservation, body mechanics, and joint protection techniques Avoid prolonged sun exposure Heart healthy diet
Polymyalgia Rheumatica tx:
Goal: suppress immune response Mild: - can be tx'ed w/ NSAIDs but typically not adequate Low dose corticosteroid is usually the first line. Prednisone - 15 mg/day initial -if symptoms are not well controlled within 1 wk of initiating therapy, increase by 5 mg to a dose of 20 mg/day - should be maintained for 2 to 4 wks after aching and stiffness have resolved and can then be gradually reduced q 2-4 wks to lowest dose needed to maintain suppression of symptoms - in pts receiving over 10 mg/day, dose can be lowered by 2.5 /day q 2-4 wks - once dose is 10 mg/day, taper 1 mg q mth, provided the clinical course is stable - May stop after 6 to 12 months if symptom free and ESR is normal Exercise/diet to strengthen the muscles and bones and improve flexibility of affected joint Rest- gives the body time to recover
Neonatal sepsis most common cause
Group B streptococcal infection - result of an intrauterine infection or can be acquired during passage through the vagina
Zinc deficiency symptoms
Growth retardation, delayed sexual maturation, impaired immune function, hair loss, eye and skin lesions, loss of appetite, impaired taste
Diphtheria symptoms
HA, fever, rapid pulse, malaise, sore throat, grey exudates, pseudomembranes on throat
Lichen Planus tx
HAIR LOSS IS OFTEN PERMANENT (this is scarring alopecia) may spontaneously resolves after 1 to 2 yrs Refer to derm, derm will do the following: - 1st line: high potency TOP corticosteroid (e.g.: Betamethasone dipropionate 0.05%, Diflorasone diacetate 0.05% cream or ointment BI) -dermatologist will be leading the tx, NP will f/u
Chronic Hepatitis B serology
HBsAG: positive Anti-HBc: positive Anti-HBs: negative ALT: elevated HBV DNA: positive/negative
anti-HCV test is positive: which test is an appropriate f/u test
HCV RNA - used to distinguish between a current or past infection (normal report: negative/not detected - may also be ordered after treatment is complete to see whether the virus has been eliminated.
Acute Hepatitis C serology
HCV antibody: nonreactive->reactive HCV RNA: detected *A detectable HCV RNA by PCR in the setting of undetectable HCV antibodies that subsequently become detectable within 12 wks is generally considered definitive proof of acute HCV infx.
Presumptive Hepatitis C serology
HCV antibody: reactive
Chronic Hepatitis C
HCV antibody: reactive HCV RNA: detected
Resolved Hepatitis C serology
HCV antibody: reactive HCV RNA: not detected
Thioziolidinedione contraindication
HF, osteoporosis, hepatic conditions
Roseola Cause:
HHV-6, HHV-7
Cervical Cancer risk factors
HPV infx/ PAP smear hx HIV infx High parity Young age at parity Diet (low in fruits and vegetables may increase risk for cervical cancer; overweight pts are more likely to develop this cancer) DES exposure PO contraceptive- studies indicate that long-term use (more than 5 yrs) may slightly increase the risk of cervical cancer
HSV-2: when to test after possible exposure
HSV-2 AB can be detected as early as 3 wks after possible exposure, but recommend waiting 4-6 wks before getting tested
Abruptio Placentae most common causes
HTN and cocaine
CAGE questionnaire
Have you ever felt you should *Cut* down on your drinking? Have people *Annoyed* you by criticizing your drinking? Have you ever felt bad or *Guilty* about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (*Eye-opener*)? *each yes is 1 point; >=2 pts is considered clinically significant
Acute Hepatitis B serology
HbsAg: positive Anti-HBc: positive Anti-HBs: negative ALT: elevated IgM Anti-HBc: positive
RSV reinfection < 50 y/o
Healthy adults are infected with RSV repeatedly throughout their lives and typically have symptoms restricted to the upper respiratory tract. In a study of 256 military trainees with respiratory symptoms, RSV infection was identified in 11 percent of patients through acute and convalescent serologic testing and real-time polymerase chain reaction (PCR)
BNP range
Heart Failure: >400 pg/mL Borderline: 100-400 pg/mL Unlikely: < 100 pg/Ml
Acute musculoskeletal injury vs Heat
Heat is not recommended first 48 hrs of injury ice it first 48 hrs then apply heat afterward
only vaccine that may be administered at birth
Hep B
Insomnia OTC
Herbal products:- little evidence any herbal products work Melatonin: not recommended as a tx for insomnia in most pts, except when sleep disturbances are d/t delayed sleep-wake phase syndrome or in pts w/ low lvls of endogenous melatonin, such as in aging. It appears to be safe when used short-term (3 mths or less) ETOH- commonly self prescribed b/c it decreases the time required to fall asleep. However, it can promote seep disturbances later in night and promotes upper airway instability and sleep apnea.
Herpes on finger tip is called
Herpetic Whitlowx
Temporal arteritis treatment
High-dose steroids (prednisone 1 mg/kg, not to exceed 60 mg, given in a single daily dose) -For pts w/ threatened or established visual loss at presentation: methyprednisolone 500-1000 mg IV daily for 3 days
Ethnic populations at risk for Diabetes Mellitus
Hispanic
Digoxin Tx:
IgG antidigoxin ABs that bind to free digoxin in blood (Digibind, DigiFab)
IgM vs IgG
IgM - recent infx, current infx IgG- past infx
Idiopathic thrombocytopenic purpura
Immune thrombocytopenic purpura (ITP) is an autoimmune syndrome characterized by the following: - Isolated thrombocytopenia (platelet count formally <100,000/mm3, typically <20,000/mm3) - Shortened platelet survival - Increased number of megakaryocytes in the bone marrow
Entresto vs ACEi/ARB
In Paradigm trial, Entresto showed a 20% reduction in risk of CV death d/t HF hospitalization over Enalapril can't be used in combo w/ ACE or ARB. *pts on ACEi must be stopped for a min of 36 hrs before the first dose Entresto can be taken . *for pts who are on ARB, they can simply stop the day before and then start Entresto the nexy day
Irritable Bowel Syndrome epidemiology <IBS risk epidemiology>
In US - occur more in middle-aged women In other parts of world - both sexes affected equally
Rubella s/s
In children, rubella is usually mild, with few noticeable symptoms. For children who do have symptoms, a red rash is typically the first sign. About 25-50% of people infected w/ rubella will not experience any symptoms If symptomatic, these symptoms occur 1-5 days before the rash - low grade fever - headache - mild conjunctiva - general discomfort - cough - lymphadenopathy - runny nose Rash generally appears on the forehead and ears then to face then spreads to the rest of the body, lasts about 3 days, other symptoms may occur
What causes pregnancy related anemia?
In pregnancy, there is an increase in plasma volume with a smaller increase in erythrocyte count, leading to relative anemia but increased whole blood volume by about 40%
Sulfonylurea MOA <diabetes>
Increase secretion of insulin by beta cells (main role) decrease glucagon release increase sensitivity to insulin
S3 heart sound
Increased ventricular filling pressure (e.g., mitral regurgitation, HF), common in dilated ventricles can be normal finding in children, pregnant females, and well-trained athletes *ken-TUC-key
Exenatide class
Incretin mimetic (acts as GLP1 Agonist)
Vaccinations: strategies to decrease pain
Infants: - breast feeding - feed sweet-tasting solutions - distraction techniques - rubbing stimulation near the site of injection All Children: - Optimizing injection technique (Avoid aspiration, Most painful injection administered last) - TOP anesthetic cream (5% Lidocaine) *PO analgesics before the vaccine are not recommended*
cerumen disimpaction method
Irrigation is one of the most widely practiced forms of cerumen removal. - saline or tap water may be just as effective - Direct otoscopy is performed after irrigation to evaluate the success of the procedure
Chronic Gestational Hypertension first line tx
Labetalol and Methyldopa *women on TZD can often be managed on their baseline med throughout pregnancy *ACE and ARB are contraindicated in pregnancy
NaCl wet mount would show which bacterium
Lacto-bacilli (most abundant microbe)
folic acid source
Leafy greens, liver, beans (soy, lentils, peas), pasta, bread, cereals Small reserve pool stored primarily in the liver.
Vitiligo tx
Limited disease: TOP corticosteroids, TOP immune-suppressants, cosmetic cover up Extensive/unresponsive disease: PO corticosteroids, topical calcineurin inhibitors, PUVA, skin bleaching, skin grafting
Lipase vs Amylase duration
Lipase: elevated at least 14 days Amylase: decreases within 24 hrs
What vaccines should be avoided during pregnancy?
Live vaccines e.g.: MMR and varicella, and live attenuated influenza vaccine
Meniere Disease: preventative management
Long-term medications: The purpose of long-term medication, such as the drug combination triamterene and hydrochlorothiazide. is to reduce fluid retention (diuretic). Reducing the amount of fluid the body retains may help regulate the fluid volume and pain and pressure in the inner ear. For some people, diuretics help control the severity and frequency of Meniere's disease symptoms. Owing to frequent urination, the body may deplete certain minerals, such as potassium. While taking diuretics, the body must be supplemented weekly with three or four extra servings of potassium-rich foods, such as bananas, cantaloupe, oranges, spinach, and sweet potatoes.2,6 - stop smoking - lower stress level - to manage vertigo, do following: dietary modifications, specifically restriction of sodium, caffeine, ETOH (but avoid severe sodium restriction for pts tx'ed w/ diuretics) -For all patients with MD with refractory symptoms (ie, recurrent vertigo) despite dietary and lifestyle interventions, we suggest the use of pharmacotherapy (Grade 2C). Betahistine and diuretics are the two options for preventative pharmacologic therapy. We suggest tx w/ betahistine rather than diuretics, when available (Grade 2C). Betahistine is well tolerated and, unlike diuretics, does not require monitoring of AE's such as hypotension, altered kidney function, and electrolyte abnormalities.
Cushing ACTH Levels Low ACTH, High ACTH
Low: -adrenal adenomas & carcinomas (primary adrenal insufficiency High: - cushing disease - ectopic ACTH production - * give high dose dexamethasone injeciton to find cause; ectopic sites won't respond
Cardioselective beta blockers (4) MEMORIZE - MANB
MANB: - Metoprolol - Atenolol - Nebivolol - Bisoprolol MEMORIZE!!!
trazodone would be prescribed for..
MDD + insomnia (b/c it has highly sedating efx) Off label: - anxiety (if other approved tx had no benefit) - insomnia 25-100 mg PO qhs -
Melasma tx:
MILD: - hydroquinone 4% once or twice daily to 4-6 mths (depigments the area) - trigger avoidance - sunscreen SEVERE: -fluocinolone, hydroquinone, tretinoin triple combination cream 2nd line tx: if TOP tx refractory, try superficial chemical peels (glycolic acid, other alpha-hydroxy acids, salicylic acid, Jessner's peel, and trichloroacetic acid) 3rd line tx: lasers and light therapy (use w/ caution to avoid postinflammatory hyperpigmentation)
when we use vanco, it is used mainly to target...
MRSA (staph) or Clostridium Difficile *note: vanco targets gram positive bacterias
pertussis mainstay abx tx
Macrolide (Azithromycin or Clarithromycin) if macrolide not tolerable, use Bactrim *only effective when bacteria are alive (Catarrhal or Early Paroxysms Phase)
beta blocker vs diabetes
Masks s/s of hypoglycemia - may harm a person's ability to recognize and respond to low blood glucose, mainly by keeping the heart rate slow, which can dampen symptoms of hypoglycemia. They may also inhibit the release of glkucose from the liver. Lowers insulin level even when blood glucose is high - BB also block the release of insulin by interacting w/ nerve signals to the pancreas Increased risk of CV events and severe hypoglycemia in pts w/ T2DM and established CV risk factors
Otitis Media with Effusion signs and symptoms <OME>
May experience mild to moderate hearing impairment The child w/ OME with not have... - Otalgia - Otorrhea - s/s systemic infx
Acne pt education
May get worse before improving, improvement seen typically in 1 to 2 months Apply topical agents to entire affected area, not just visible lesions. Mild soap daily to control oiliness; avoid abrasives. Oil-free, noncomedogenic sunscreens Gentle cleanser and noncomedogenic moisturizer help decrease irritation. Stress management if acne flares with stress
Glaucoma s/s
May see halos around lights normally painless *Loss of Peripheral Vision* (tunnel vision) cloudy, blurry, artificial lights seem to have rainbows/halos (increased IOP, obstruction of aqueous humor)
when to refer a pt for prostate cancer eval
Men with a PSA level above 7 ng/mL should be referred, without further testing, to a urologist for evaluation. •For men with a PSA level between 4 and 7 ng/mL, we repeat the PSA testing several weeks later. Factors known to transiently increase PSA should be addressed prior to repeating the PSA test (see 'Reasons to temporarily defer PSA testing' above). Men with a repeat PSA level >4 ng/mL should be referred to a urologist for evaluation.
Menveo vs Menactra
Menveo (MenACWY-CRM) is approved for children 2 mths and older MenACWY-D (Menactra) is approved for children age 9 mths and older
Methimazole vs pregnancy
Methimazole has risk of congenital defects in the first trimester, so use PTU instead
Bacterial Vaginosis pharmacologic intervention
Metronidazole 500 mg PO BID for 7 days OR Metronidazole gel 0.75% one full applicator (5g) intravaginally once a day for 5 days OR Clindamycin cream 2, one full applicator (5 g) intravaginally) qhs for 7 days *alternative regimens -Tinidazole 2 gram PO QD for 2 days -Tinidazole 1 gram PO QD for 5 days -Clindamycin 30 mg PO BID for 7 days -Clindamycin ovules 100 mg intravaginally qhs for 3 days
Tinea Cruris preventative pharmacologic intervention
Miconazole nitrate (Zeasorb-AF) - drying powder can be dusted into the involved area in pts w/ excessive perspiration or occlusion of skin d/t obesity as a preventative measure
G6PD deficiency dx
Microscope: bite cells, heinz bodies G6PD low after hemolytic episode -findings of hemolytic anemia -decreased rbc -increased lvl reticulocyte -high lvl of LDH -high bilirubin -low haptoglobin (binds to free hgb) -negative Coombs test *definitive test: enzyme assay to detect G6PD lvl many newborns are tested after birth
Asymptomatic Bacteriuria Diagnostic Criteria
Midstream clean-catch urine -female: 2 consecutive specimens w/ isolation of same species >= 100,000 CFU/mL -male: a single specimen w/ one bacterial >=100,000 CFU/mL Catheterized urine: -both female and male: single specimen >= 100 CFU/mL
Acne tx
Mild first line: - Comedonal: TOP Keratinolytic agent (Adapalene, retinoid, salicylic acid, azelaic acid) - Inflammatory: benzoyl peroxide or TOP retinoid or benzoyl peroxide +/- TOP abx +/- TOP retinoid Moderate first line: - above + PO abx in females: Ortho Tri-cyclen (OCP) *Wean PO abx after 3-5 mths Severe first line: - topical (like above) + accutane AND/OR consider dermatology consult * NEVER give tetracycline with accutane!! * Maintenance first line: - Topical retinoids are first-line agents for maintenance therapy. Meds: - Benzoyl Peroxide gels (2,5, & 10%) (has antibacterial, antikeratolytic, and comedolytic activity; effective as monotherapy); 2.5% is as effective as 10% but less irritating - Adapalene (Differin): 0.1%, apply topically at night First FDA-approved over-the-counter (OTC) retinoid much less expensive than other Rx retinoids ($10 to $15 per tube).; May be combined with benzoyl peroxide (Epiduo)- 0.1 or 0.3%/2.5%—very effective in skin of color - TOP Tretinoin IRRITATING! (moa: act to normalize desquamation by reducing keratinocyte proliferation and promoting differentiation. They also block several important inflammatory pathways that are activated in acne), Retinoic acid is the less concentrated version of tretinoin - TOP abx: Clindamycin /Erythromycin - Benzoyl peroxide-clindamycin (BenzaClin, DUAC, Clindoxyl) - Benzoyl peroxide-erythromycin (Benzamycin): especially effective with azelaic acid
antidepressant that would be prescribed to underweight pt
Mirtazapine (has SE of wt gain) *many other meds have SE of wt gain (most likey to cause wt gain include Amitriptyline (Elavil), Mirtazapine (Remeron), Paroxetine (Paxil), Escitalopram (Lexapro), Sertraline (Zoloft), Duloxetine (Cymbalta), Citalopram (Celexa))
LTRA list
Montelukast (Singulair.) Zafirlukast (Accolate)
amlodipine common side effects
More common - *Swelling of lower extremities* Less common - Fatigue - Dizziness - Palpitation - Redness of face, neck, arms, occasionally, upper chest - Feeling of warmth Rare: - black, tarry stools, - bleding gums - blurred vision - confusion - etc
intermediate acting insulin list
NPH (Humulin N, Novolin N)
As the pt awaits the rheumatology appt for RA, what might you consider prescribing as a PCP?
NSAID and/or corticosteroid (symptom control or acute flare-ups - Naproxen 250 mg tab 1 tab PO BID, max 1500 mg/day - prednisone 1-10 mg PO once daily for mild RA, give w/ food
Reactive Arthritis tx
NSAIDs - Naproxen 500 mg PO BID/TID - diclofenac 5 mg TID - Indomethacin 50 mg ID
Gout tx (1st line pharm)
Naproxen 500 mg PO BID OR Indomethacin 50 mg TID OR Colchicine 1.2 mg PO single dose at first onset then 0.6 mg PO 1 hr afterward, then 0.6 mg PO TID a day until pain lessens then 0.6 mg PO QD or BID until complete resolution + 2 days(Max 6 mg during on tx course)
Ethnic populations at risk for alcohol abuse
Native Americans -Asians are at lower risk
Simethicone SE
Nausea and constipation possible but rare
Impetigo: principal pathogen
Nonbullous impetigo is most commonly caused by S aureus which is responsible for 80% of cases. Group A beta-hemolytic Strep (GABHS) accounts for 10% of cases and the causative agent is a combination of S. aureus and GABHS 10% of the time. MRSA has become more prevalent, especially in hospitalized pts. Today, community-acquired MRSA is rapidly increasing. The condition is more common in populations living in close quarters, daycare centers and prisons. Bullous impetigo is caused almost exclusively by S aureus. Sometimes a deep ulcerated infection may occur known as ecthyma, which is a complication of bullous impetigo.
Nondihydropyridine CCB vs Dihydropyridine CCB
Nondihydropyridine CCB: - vasodilation + myocardial depression (decreased HR, conduction, contractility, antiarrhythmic) Dihydropyridine CCB: - vasodilation, less myocardial effx - has greater selectivity for vascular smooth muscle than for the myocardium, making the more potent vasodilators than either Verapamil or Diltiazem
Emergency Contraceptive contraindications
None - although migraine w/ aura and CV disease are contraindications to estrogen-containing contraceptive methods, according to the CDC Medical Eligibility Criteria for contraceptive use, there are no medical contraindications for emergency contraceptive use (other than allergy to components of the med) (for example, the estrogen-containing emergency contraceptive regimen is not likely to have the same clinical pro-thrombotic effx as prolonged use of estrogen-containing contraceptives
Herpangina tx
None :) Coxsackie virus is self-limited cold beverages recommended; hot or high acidity beverages are to be avoided; popsicle can also help soothe sore throat Salt and warm water gargle QD - relieve pain and sensitivity Oral lozenges containing dyclonine (Sucrets) may be used for soreness. Avoid spicy, crunchy, fried, salty or acidic food - may make the pain and discomfort worse
Fibromyalgia Tx:
Nonpharmacological: try these first before meds 1. exercise (fast walking, biking, swimming, water aerobics for 20-30 mins two or three days / week) 2. relaxation techniques 3. Sleep hygiene Pharm 1. Amitriptyline (TCA)(help increase serotonin and norepinephrine lvl) 2. SNRI (help increase serotonin and norepinephrine lvl) 3. Anticonvulsant Pregabalin, Gabapentin (slow nerve impulses and help sleep
Troponin I levels
Normal < 0.04 ng/mL Probable heart attack: > 0.4 ng/mL
what is nitrite?
Normal urine contains chemicals called nitrates. If bacteria enter the urinary tract, nitrates can turn into different, similarly named chemicals called nitrites. Nitrites in urine may be a sign of a urinary tract infection (UTI).
HgbA1C level -normal -prediabetic -diabetic
Normal: Below 5.7 % Prediabetes: 5.7 - 6.4% Diabetes: 6.5% or higher
Gonorrhea dx
Nuclear Acid Amplification Test - can be urine or swab
osteoarthritis diagnosis
OA may be dx'ed clinically w/o radiography and/or laboratory investigation *in presence of typical s/s in the at-risk age group* if following are met - Peripheral joint OA present - Persistent usage-related joint pain in one or few joints - Age >=45 y/o - Morning stiffness <= 30 mins Distinguish OA from other tpyes of arthritis by: - Absence of systemic findings - Minimal articular inflammation - distribution of involved joints
IPV vs OPV use
OPV is more used in countires where polio is endemic
dramamine
OTC motion sickness med
Yellow fever vaccine schedule
One SQ injection for people 9 mths or older who travel to endemic regions of Africa and South America booster q 10 yrs
Polymyalgia Rheumatica clinical manifestation
Onset can be abrupt, sometimes startingly so Symmetrical aching/stiffness about the neck, shoulders, upper arm, hip girdle, and lumbar area, worst on arising in the morning NO MUSCLE WEAKNESS morning gelling (stiffness w/ inactivity) that is noticeable more severe than other rheumatic diseases in general - proximal joint and neck symptoms worst w/ inactivity, results in nocturnal pain and prominent morning stiffness - its absence excludes the diagnosis of PMR -*Morning stiffness last > 1 hr and often all morning is common Pain worsens at night (nocturnal gelling is common) nonspecific systemic s/s: - malaise/ fatigue - depression, anorexia - wt loss - low-grade fever Many pts develop temporal arteritis (causes symptoms like severe headache, jaw pain, vision problems, even blindness) Functional limitations: proximal stiffness can result in difficulties w/ ADL; such as pulling on a shirt, hooking a bra in the back. The intensity of gel phenomenon, coupled w/ proximal stiffness, can be such that pts require assistance w/ morning dressing
Diazepam - Onset - Duration - Half Life
Onset: 15-1 hr (is rapid onset) Duration: 6-8 hours Half life: 48 hours
Lorazepam (Ativan) - Onset - Duration of action
Onset: 30-60 mins Duration:6-8 hrs
Uveitis work up
Ophtalmologist does the following work up slit lamp exam and dilated fundus exam
aphthous stomatitis tx
Oral hygiene - a soft toothbrush - nonalcoholic containing mouthwash is often less irritating but still effective - Less aggressive, more frequent professional dental cleaning is advised. - Rinse your mouth with salt water. To make a salt water rinse, dissolve 1 tsp (5 g) of salt in 1 cup (250 mL) of warm water. avoid exacerbating factors - reduce traumatic factors inside the mouth - avoid habits that cause trauma (biting cheeks or lips) - avoid foods that seem to exacerbate the process (coffee, chocolate, spicy or salty foods, citrus fruits or juices, nuts, seeds, and tomatoes) pain control - 2% viscous lidocaine (Our first choice is 2% viscous lidocaine. It is available by prescription and generally effective for limited pain control.) - diphenhydramine liquid- siwsh and spit - Dyclonine lozenges: dissolve slowly in mouth - Attapulgite suspension: 600 to 750 mg/15 mL; 5 to 10 mL swish and spit Pts w/ simple aphthosis - TOP corticosteroid as first line for mild to moderate RAS; more effective if initiated early in the course of an episode and used frequently for at least few days -
Ottawa Ankle Rules
Order ANKLE films if: Pain in the malleolar zone -AND- Bone tenderness at the posterior edge or tip of the lateral or medial malleolus OR unable to bear wt both immediately after the injury and for 4 steps in the emergency room (palpate 6 cm of posterior edge of lateral or medial malleolus) Order FOOT films if... Pain in the midfoot zone -AND- Bone tenderness at the base of the 5th metatarsal or at the navicular OR unable to bear wt both immediately after the injury and for 4 steps in the emergency department *If the patient can transfer wt twice to each foot (4 steps), he is considred able to bear wt even if he limps *palpate teh distal 6 cm of the posterior edge of the fibula when assessing for bone tenderness
Acute Pelvic Pain ddx
Ovarian - cyst - torsion - PID w/ or w/o Tubo Ovarian Abscess - Malignancy Uterine - Fibroids/ademyosis - Dysmenorrhea - PID - SAB- Spontaneous Abortion Tubal -Ectopic - Tubo Ovarian Abscess Urinary - UTI Bowel - Viral - Gas - Constipationl
before checking the ACL laxity, check what?
PCL injury (using posterior drawer) -A false positive anterior drawer test can occur if a posterior cruciate ligament (PCL) injury exists.
Diverticulitis Dx
PE findings Labs (very early in the disease process, labs may be of limited benefits BUT CHECK ANYWAY; you don't necessarily mount WBC early on) -CBC (may have leukocytosis) - CRP (may be elevated) - UA (UTI) - pregnancy test - supine and upright plain abdominal films (appropriate, but will only tell if there is free air (bowel perforation), bowel obstruction, or ileus; will not visualize diverticuli or abscess) -electrolytes Imaging (CT scan pref) is required for confirmation -US -Flexible sigmoidoscopy (not when acute belly; in general you are always referring to GI for the sigmoidoscopy)
PPSV23 schedule
PEDS: single dose, 8 wks after PCV13 series is complete - given to children 2 years or older w/ special medical condition two doses, if child has following conditions (2nd dose at least 5 yrs later) - SCD - congenital or acquired asplenia - splenic dysfunction - HIV infx - CKD - nephrotic syndrome - congenital syndrome - congenital immunodeficiency - immunosuppressive drug tx - radiation therapy 19-64: If in highest risk, give 1 dose PPSV23 only, revaccinate after 5 years . These include: - chronic heart (excluding HTN) - lung disease - liver disease - diabetes - alcoholism - cigarette smoking If immunocompromised, - cochlear implant, or CSF leak - PPSV23 8 wks after PCV13 65 or older: - shared clinical decision making- give PPSV23 1 year after PCV13 (8 wks after if + HIV, immunocompromised, or asplenic) - no need for repeat dose of PPSV23
Misoprostol use
PGE1 derivative: orally active prostaglandin used to prevent peptic ulcers in patients taking NSAIDs for arthritis. Tox: diarrhea
route of administration: rotavirus
PO
Preseptal Cellulitis tx
PO ABX against: S. aureus S. pneumoniae H. influenzae IV ABX children PO ABX adults
Traveler's diarrhea pregnant mom tx
PO Hydration most important Quinolones (FDA pregnancy category C) generally are not advised during pregnancy, but azithromycin (FDA pregnancy category B) is safe.
Iron Deficiency Anemia follow up
PO Iron: reevaluate in 2 wks, check hgb and reticulocyte ct and review tolerability of PO iron IV Iron: reevaluate in 4-8 wks after iron is administered. We do not obtain repeat iron parameters for at least 4 wks, b/c IV iron interferes w/ most assays of iron status
TZD route of administration
PO tablets, taken w/o regards to food
Sulfonylurea route of administration <diabetes>
PO tabs
Alpha Glucosidase Inhibitor route of administration
PO tabs, taken at start of each meal
Meglitinide route of administration
PO tabs, taken at start of the meal
DPP-4 inhibitor route of administration
PO tabs, taken once a day
SGLT2 inhibitor
PO tabs, taken once a day
for men who choose prostate cancer screening, we suggest...
PSA blood test alone. Digital rectal examination (DRE) is generally not used as a screening test for prostate cancer, either alone or in combination with a PSA test.
Pregnant mom w/ syphilis: how to tx?
Parenteral PCN G IM is the only therapy effective -pt should be desensitized and tx'ed w/ PCN
PEDS screening stands for..
Parents' Evaluation of Developmental Status
erythema infectiosum cause
Parvovirus B19
animal bites microbiology
Pasteurella spp- isolated from 50% of dog bite wounds and 75% of cat bite wounds (incubation period 1-3 days) Capnocytophaga spp - Capnocytophaga canimorsus can cause bacteremia and fatal sepsis after animal bites, especially in patients with asplenia, alcoholism, or underlying hepatic disease
DVT nursing interventions
Patient on bedrest until anticoagulant is started to prevent pulmonary embolisms, monitor peripheral pulses, administer anticoagulants, elevate legs, apply warm moist packs
Lexapro vs Paxil
Paxil has, in addition to icnreasing serotonin and blcking reuptake, some mild anticholinergic effects so you will see more weight gain and sedatikon with that.
Erythema Multiforme epidemiology
Peak incidence in 20s to 40s rare <3 years and >50 years of age
Chronic Pelvic Pain ddx
Pelvic floor dysfunction Endometriosis Adhesion Pelvic congestion syndrome Acute issues that have not been tx'ed Psychogenic disorders Bowels (IBS, colitis, Crohn's) Interstitial cystitis
Norovirus: duration of contagious
People infected with norovirus are contagious from the moment they begin feeling ill to at least 3 days after recovery.
diabete blood pressure goal
Per AACE 2020: <130 systolic <80 diastolic Per JNC8: <140/90mmHg
Chlamydia liver complication
Perihepatitis (Fitz-Hugh-Curtis syndrome) - inflammation of the liver capsule and adjacent peritoneal surfaces -typically no liver enzyme abnormalities - commonly seen in the settin of acute PID, occuring in 5 to up to 15 eprcent of cases - pathoenesis is not fully understood
Tinea general prevention guide
Personal hygiene including regular shampooing of hair, change socks frequently dry site (moist environment is favored by dermatophyte)' pet- treat household pets to prevent recurrence *corn starch may exacerbater fundal infection
Acute Otitis Media dx<AOM>
Pneumatic Otoscopy - Red inflamed bulging tympanic membrane OR very infrequently, other signs of acute inflammation and middle ear effusion - TM does not move w/ insufflation *marked redness of TM w/o bulging is unusual in AOM and has a positive predictive value of only 15% for AOM Child will have following s/s... - *systemic symptoms (fever, malaise) - *moderate to severe otalgia - mild to moderate impaired hearing - Otorrhea (only after perforation of tympanic membrane)
Giant Cell Arteritis is a/w which rheumatic disease...
Polymyalgia Rheumatica
FDA Category C
Positive animal fetal harm AND no adequate human studies *potential benefits may warrant the use in pregnant women despite potential risks.
FDA Category D
Positive evidence of human fetal risk *potential benefits may warrant the use in pregnant women despite potential risks.
Rubella Dx:
Postnatal Rubella: - ELISA (cheap, check for IgM which is for recent/current infx) - Rubella viral culture (expensive, used mostly for tracking epidemiology) Congenital Rubella - Viral isolation (preferred technique) - PCR (throat, nasal, or urine sample)
orthostatic hypotension dx
Postural hypotension is dx'ed when, within 2-5 mins of quiet standing (after 5 min period of supine rest), one or both of the following is present - at least 20 mmHg fall in systolic pressure - at least 10 mmHg fall in diastolic pressure HR normally rises immediately on standing. the absence of an appropriate reflex-induced increase in HR as the BP falls is a useful clinical clue to the presence of autonomic failure; however, the presence of a HR increase does not exclude autonomic failure.
Intermediate acting glucocorticoids
Prednisone (12-36 hrs) Prednisolone (12-36 hrs) Methylprednisolone (12-36 hrs) Triamcinolone (12-36 hrs)
telogen effluvium def
Premature shedding of hair resulting from the early entry of hair in the telogen phasemostly due to stress- this causes asynchronous growth
Medicare D covers
Prescription drug coverage
Mirena vs Liletta differences
Pretty much same thing; Liletta was designed w/ cost in mind (so it's lot cheaper)
Zinc source
Primary dietary sources of zinc include animal products such as meat, seafood, milk and fortified cereal. Sufficient dietary zinc sources are available in a typical mixed diet
Addison/ Adrenal Insufficiency primary vs secondary vs tertiary def
Primary: disease of the adrenal gland Secondary: interference w/ corticotropin Tertiary: interference w/ CRH by hypothalamus
Varicella sxs
Prodromal symptoms: fever (low grade to moderate and persists after rash appears), malaise, anorexia, mild headache - Malaise, muscle aches, arthralgias, and headache are more common in adults. Subclinical in ~4% of cases Characteristic rash: crops of vesicles on erythematous bases ("dew drops on a rose petal"), doesn't have dermatome distribution Progress from macule to papule to vesicle and then begin to crust Pruritic rash is present in various stages of development. Lesions may be present on mucous membranes, both oral and vaginal.
Postpartum period: when can I start taking contraceptive
Progestin: right away any contraceptive containing estrogen: wait at leasst 3 wks d/t high risk of VTE.
Migraine prophylaxis
Propranolol, topiramate, CCBs, amitriptyline
Cimetidine Pros and Cons
Pros: - works very well for heartburn - longer lasting (so less frequent dosing) Cons: - tad bit expensive (25 dollars OTC) - may have more SE than other ones
Misoprostol class
Prostaglandin E1 analogue
ADHD diagnosis
R/o... -impaired vision -hearing problems -lead poisoning -anemia -hyperthyroidism -depression -mania -anxiety disorder -substance use disorder Clinical tool: -Vanderbilt (children) -Adult ADHD self-report scale (ASRS)— For assessing adults in primary care for ADHD, ASRS is a brief and practical choice. Medical examination - necessary to rule out medical conditions such as brain tumor, or seizures. Clinical interview - provides information about the child's physical and psychological characteristics, as well as family dynamics and interaction with peers. Teacher and parent rating scales - rate "how often" the individual doesn't pay attention. behavioral observations - observe the child performing tasks that require sustained attention.
Multiple Sclerosis tx
RRMS (rapidly remitting multiple sclerosis) - goal: lessen the severity of relapses and frequency - Corticosteroids (mainstay), cyclophosphamide (cell cycle inhibitor), IVIG - Plasmapheresis: remove autoantibodies - Immunosuppressants Progressive MS - fewer options available - manage symptoms (depression, bladder dysfunction) - Physical therapy - Cognitive rehab therapy - there is increasing interest in Vit D for tx
Fifth's Disease: S/S
Rash appears in 3 stages: 1. Slapped face appearance Maculopapular rash; 2. Distributed to upper and lower extremities, progresses from proximal to distal 3. Rash subsides and reappears if skin is irritated (especially by sunlight)
Alopecia Areata Tx
Refer to derm Spontaneous remission occurs in patchy AA, but less commonly in AAT or AAU Derm will do following tx: - mainstay: Intralesional triamcinolone acetonide injected intradermally (may be repeated every 4 to 6 wks until resolution or for a maximum of 6 mths. Local AE's include transient atrophy and telangiectasia) - TOP CS if unlikely to tolerate intralesional CS injections - TOP immunotherapy if above therapies dont' work
COPD s/s (many, know 10)
Respiratory: Chronic cough Persistent morning cough Dyspnea Tachypnea Wheezing Sputum production Prolonged expiration Inspiratory crackles "Pursed lip" breathing Hypoxemia Hypercapnia Abnormal, diminished, or absent lung sounds Pulmonary HTN Cardiac/Chest: Cardiac R ventricular hypertrophy Cor pulmonale chest tightness Barrel chest Other: Mental status changes Clubbed nails Tripod position Polycythemia Weak thigh muscles
Acromioclavicular sprain cause
Result of direct blow (from any direction), upward force from humerus, fall on outstretched arm
Rocky Mountain Spotted Fever cause
Rickettsia rickettsia (bacteria), spread by ticks
medications that interefere w/ contraceptions
Rifampin griseofulvin certain HIV meds St John's wort certain antiseizure meds
JVD is a sign of
Right sided heart failure and Tension pneumothorax
diabetes lipid goals
Risk Classifications: - High Risk: DM but no other major risk and/or age <40 - Very High: DM + major ASCVD risks (HTN, fam hx, low HDL-C, smoking, CKD 3,4) - Extreme: DM plus established clinical CVD High Risk Goals: - LDL-C < 100 - Non-HDL-C < 130 - TG < 150 - Apo B < 90 Very High Goals: - LDL-C < 70 - Non-HDL-C < 100 - TG < 150 - Apo B < 80 Extreme Goals: - LDL-C < 55 - Non-HDL-C < 80 - TG < 150 - Apo B < 70
Bupropion BBW
Risk of suicidal thinking and behavior is increased in children, adolescents, and young adults taking antidepressants
Functional Constipation criteria
Rome III Diagnostic Criteria at least 2 of 6 in child w/ a developmental age younger than 4 years - 2 or fewer BM in a week - Hx excessive stool retention - Hx retentive posturing or excessive volitional stool retention - Hx painful or hard bowel movements - Presence of large fecal mass in rectum - Hx fecal incontinence
Adult Functional Constipation criteria
Rome III Diagnostic Criteria for Functional Constipation must include 2 or more of the following: - Straining during at least 25% of defecations - Lumpy or hard stools in at least 25% of defecations - Sensation of incomplete evacuation for at least 25% of defecations - Sensation of anorectal obstruction/blockage for at least 25% of defecations - Manual maneuvers to facilitate at least 25% of defecations (e.g. digital evac, support of the pelvic floor) - Fewer than 3 defecations per wk
Rotavirus schedule
RotaTeq 3 doses: 2,4 ,6 mths Rotarix 2 doses: 2, 4 mths *all must be given before age 8 mths and 0 days *all must be given w/ at least 4 weeks apart
most common cause of acute gastroenteritis in pts under 2 y/o
Rotavirus - most common in 3-15 mths
vaccines given at 6 weeks include
Rotavirus, DTaP HiB PCV13 IPV
PCOS dx
Rotterdam criteria (2 of 3 minimum) - abnormal uterine bleed (Oligomenorrhea or amenorrhea) - cysts on imaging - hyperandrogenism
Community acquired pneumonia common causes
S. pneumoniae (most common) Haemophilus influenza (ampicillin-sensitive/resistant strains) Moraxella catarrhalis (all strains are penicillin-resistant)
Splitting heart sound is noted with which heart sound
S1 and S2
CHF produces what heart sound
S3 -ken-TUC-key
ventricular hypertrophy makes what heart sound
S4
SCOFF questionnaire
S: Have you ever made yourself Sick (such as by vomiting) because you felt too full or uncomfortably full? - "have you ever made yourself too sick (such as by vomting) because you felt too full w/ food or uncomfortably full? C: do you worry that you have lost Control over how much you eat? - "do you worry about controlling your diet or do you also worry that maybe you lose control sometimes over how much you eat?" O: have you recently lost more than One Stone (14 lb (6.4 kg)) in a 3 mth period? - "have you recently lost more than 14 lbs (6.4 kg) in a 3 mth period?" F: do you think you are too Fat, even though other people say you are too thin? - "do you think you have a high BMI even when other people say you are lean?" F: would you say that Food dominates your life? - "would you say that food is a dominant factor in your life?" *One point for every yes answer; >=2 pts should indicate high suspicion of anorexia nervosa or bulimia nervosa (sensitivity 100%, specificity 87.5%)
Exercise induced bronchoconstriction prophylaxis
SABA 2 puffs OR Cromolyn 2 puffs (in combination w/ SABA) OR combination budesonide-formoterol (Symbicort) 15-20 mins prior to exercise *Ipratropium generally not used for quick relief be/c bronchodilation is delayed *Cromolyn will not relieve s/s that already developed
COPD tx for group A
SABA PRN dyspnea OR SABA + SAMA (more effective d/t additive effect of combo) - SABA- Albuterol, Levalbuterol proven in randomized trials and meta-analyses to improve s/s and lung function - SAMA- Ipratropium (commonly used, most studied) *Combination therapy is often preferred because the combination of a short-acting beta agonist plus a short-acting muscarinic antagonist achieves a greater bronchodilator response than either one alone [17]. However, monotherapy with either agent is acceptable.
actinic keratosis can turn into .... when...
SCC when partial thickness becomes full epidermal thickness (this is called Squamous Cell Carcinoma In Situ)
SGLT2 MOA
SGLT2 inhibitor - inhibits Sodium-glucose cotransporter-2 I(SGLT2) in the kidney, thereby preventing reuptake of most filtered glucose by the kidney
-flozin meds are what class of meds?
SGLT2 inhibitors
ANA is typically positive in...
SLE - usually, high titers (>1:160) are more specific for lupus
Panic Attack FDA approved pharm
SSRI - fluoxetine (Prozac) - not often used by doc - paroxetine (Paxil) *- Sertraline (Zoloft)* - recommended by doc (Lexapro not FDA approved but may work just as well, according to doc) SNRI - Venlafaxine hydrochloride (Effexor XR) - works Benzo - Alprazolam - Clonazepam
can SSRI cause insomnia
SSRI may cause insomnia
Antidepressant Withdrawal Syndrome involve mostly which meds
SSRI, SNRI - some pts may develop extreme irritability to other class of meds
PTSD 1st line treatment
SSRI, TCA, MAOI
Streptococcal Pharyngitis clinical manifestations
SUDDEN onset of... - headache - fever - sore throat - swollen tonsils - erythematous pharynx - white/yellow pus on side or back of throat *No viral URI sxs: coughs, coryza, rhinorrhea, conjuncitivits noted
Sucralfate sig
SUSP: 1 gram per 10 mL sig: take 10 ml PO QID 1 hr before meals, bedtime
examples of LABAs include
Salmeterol (Serevent) BID Formoterol (Foradil) BID
LABA list (5)
Salmeterol (Serevent) BID using Discus or MDI Formoterol (Perforomist) BID via NEB Olodaterol (Stiverdi) QD via Respimat Arformoterol (Brovana) via NEB Indacaterol (Arcapta) QD via Ellipta
Advair BID is composed of
Salmeterol + Fluticasone
Hypothyroidism s/s
Same as hypometabolism tired, sluggish Cold intolerant obese decreased hr, p, rr Bradycardia Constipation Periorbital edema Poor hearing Fatigue Decreased sensation
Uveitis Tx:
Same day referral to an ophthalmology specialist is indicated for the diagnosis and management of most patients with symptoms suggesting uveal tract inflammation. - Tx w/ TOP steroids is the mainstay of therapy for acute anterior uveitis, but this therapy can backfire if the process is caused by an infx (especially herpes keratitis). This is the reason why sliplamp exam by ophthalmology is very useful -TOP steroids can also contribute to cataract formation as well as the development glaucoma -Cycloplegics drops to control pain
USPSTF Chlamydia screening recommendations
Screen sexually active women ≤24 or >25 who are at increased risk (e.g. new sexual partners, more than 1 concomittant sexual partner, known STI in a sexual partner, inconsistent condom use) -USPSTF recommends screening for chlamydia in a sexually active women younger than age r24 because this group has the highest incidence of chlamydia Insufficient evidence to recommend for or against the screening of men
USPSTF recommendation screening pt w/ family hx breast, ovarian, tubal, or peritoneal cancer
Screen using risk tool such as Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, and FHS-7. If screening is positive, perform tests next -they elicit info about factors that are a/w an increased likelihood of BRCA mutations. -family hx a/w increased likelihood of potentially harmful BRCA mutations include breast cancer dx before age 50, bilateral breast cancer, presence of breast and ovarian cancer, presence of breast cancer in >= 1 male family members, multiple cases of breast cancer in the family, >= 1 family members w/ 2 primary types of BRCA-related cancer, and Ashkenazi Jewish ethnicity
Narcolepsy dx
Screen w/ Epworth Sleepiness Scale (ESS)1 and the Swiss Narcolepsy Scale (SNS) Polysomnography multiple sleep latency test Type 1 criteria: (w/ cataplexy) - at least 3 mths of daily periods of irrepressible need to sleep or daytime lapses into sleep - one of the following: cataplexy and a mean sleep latency of <= 8 mins and 2 or more sleep onset REM (SOREMP) sleep periods on multiple sleep latency test( MSLT). (*A SOREMP (within 15 mins of sleep onset) on a preceding nocturnal polysomnogram may replace 1 of the SOREMPs on the MSLT) Type 2 Criteria: (w/o cataplexy) -an overnight PSG followed the next day by an MSLT that demonstrates a mean sleep latency <= 8 mins and at least 2 SOREMPs -dx of narcolepsy type 2 hinges upon the MSLT, yet the MSLT has several limitations and poor reproducibility in narcolepsy type 2 patients. Consequently, it is sometimes hard to be certain if a patient has narcolepsy type 2 or idiopathic hypersomnia [128,137]. In the absence of a specific biomarker, clinical judgment is crucial: Does the patient have symptoms suggestive of REM sleep dysfunction (eg, frequent sleep paralysis or hypnagogic hallucinations) indicative of narcolepsy, or nonrestorative, long sleep with troublesome morning sleep inertia indicative of idiopathic hypersomnia?
Temporal arteritis diagnosis
Screen with ESR, but need temporal artery biopsy to diagnose.
Developmental Screening definition
Screening is a "brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment."3 Developmental screening is aimed at identifying children who may need more comprehensive evaluation. It communicates the pediatrician's interest in the child's development, not just his or her physical health.4 Developmental evaluation may lead to a definitive diagnosis, development of an interdisciplinary comprehensive plan of remediation, realization that there is no significant problem, or a decision that additional observation is warranted.
Parkinson's disease is closely a/w which skin disorder
Seborrhea Keratosis
Seborrheic dermatitis prevention
Seborrheic skin should be washed more often than usual to soften the affected areas. SCALP: - antifungal shampoo once a week may be helpful to prevent relapse
Atypical Antipsychotics refer to...
Second Generation Antipsychotic
meglitinide MOA
Secretotogue so same as Sulfonylureas, but shorter acting...works with meals
croup prognosis
Self-limited illness and the cough typically resolves within three days. Other symptoms may persist for seven days with a gradual return to normal [1]. Deviation from this expected course should prompt consideration of diagnoses other than laryngotracheitis.
Vitamin D Deficiency def Vitamin D Insufficiency def
Serum 25-hydroxyvitamin D lvl < 12 ng/mL Insufficiency: 25-hydroxyvitamin D lvl between 12-20 ng/mL
what does salt gargle do?
Several studies have found that gargling several times a day with warm saltwater can reduce swelling in the throat and loosen mucus, helping to flush out irritants or bacteria. Doctors generally recommend dissolving half a teaspoon of salt in one cup of water
Brown urine may be due to..
Severe dehydration Liver disease
Ankle Sprain Grade I
Severity: mild Physical Damage: overstretching or slight tearing of a ligament. Symptoms: slight pain, possible slight bruising, swelling, able to put weight on the affected area tx: PRICE; foot ankle circles; NSAID; Ottawa rule before X-ray
Ankle Sprain Grade II
Severity: moderate Physical Damage: partial tearing of a ligament Symptoms: moderate pain, bruising, swelling, some difficulty putting weight on the affected area; some loss of RoM and function Tx: PRICE; foot ankle circle exercise; sustained support following their injury (The combination of an elastic wrap and an Aircast or similar splint for few wks); NSAID; Ottawa rule before X-ray, referral to an orthopedic physician;
Ankle Sprain Grade III
Severity: severe Physical Damage: complete tear of a ligament Symptoms: severe pain, bruising, and swelling, as well as the inability to put weight on the affected area; UNABLE TO BEAR WT OR WALK; usually requires immobilizing the area to decrease the risk of future injury to the area; tenderness in posterior edge of the lateral or medial malleolus Tx: refer to ED
Sjogren Syndrome Diagnostic
Sialometry- measure saliva flow lab - Anti-SS-A, Anti-SS-B - ANA
Silvadene: main ingredients?
Silver Sulfadiazine has: - Silver - Sulfa abx
COPD management <quick list>
Smoking cessation Bronchodilators - Ipratropium bromide: 1st line - Albuterol, metaproterenol - Theophylline - Formoterol, Salmeterol, and anticholinergic - Dieteray management Corticosteroids Immunizations: flu, pneumonia Long-term oxygen therapy if chronic hypoxemia Antibiotics Noninvasive positive pressure ventilation Education Exercise Psychological support Nutrition Surgery
bupropion use
Smoking cessation, atypical antidepressant.
Aldosterone Antagonist list
Spironolactone (Aldactone) Eplerenone (Inspra)
Active TB monitoring <tuberculosis>
Sputum should be obtained for acid-fast bacilli (AFB) smear and culture at mthly intervals until 2 consecutive cultures are negative
Lyme disease s/s
Stage 1 (Early Lyme Disease, 7-14 days after bite) - Some patients may be asymptomatic - Erythema migrans (non pruritic) - lymphadenopathy - flu-like symptoms - systemic sxs: Malaise, fatigue, headache, myalgias Stage 2 (Early disseminated Lyme disease; occurs weeks to mths later) - expanding rashes - Migratory musculoskeletal pain - Cardiac: "Lyme carditis" (pleuritic chest pain; palpitations); cardiac conduction block (1st, 2nd, 3rd) - CNS sxs: pain and weakness in arms and legs, facial palsies or other cranial neuropathies, meningitis, difficulty concentrating - Iritis, conjunctivitis - joint swelling , redness, pain Joint pain (polyarthritis/polyarthralgia; late disease: monoarthritis-like knee) Stage 3 (Late Lyme disease; occurs years later) - arthritis (can be monoarticular or oligoarticular) - neurological: neuropathy (motor, sensory, or autonomic neuropathies), meningitis, encephalopathy, problems w/ memory; confusion; facial palsy; nerve pain; severe headaches and neck stiffness - pericarditis - recurrent tendonitis, bursitis, synovitis
Lyme Disease Tx
Stage 1: - Doxycyline 100 mg BID for 14-21 days - PEDS: Azithromycin 10 mg/kg Stage 2-3: - Ceftriaxone *refer pt as well if presenting cardiac or neurological involvement *Testing and treatment not indicated if tick attached for <48 hours
ACC/AHA HF Classification
Stage A: those at risk for heart failure, but who have not yet developed structural heart changes (diabetics, those w/ coronary disease w/o prior infarct) Stage B: individuals w/ structural heart disease (eg reduced ejection fraction, left ventricular hypertrophy, chamber enlargement), however, no symptoms of heart failure have ever developed Stage C: pts who have developed clinical heart failure Stage D: pts w/ refractory heart failure requiring advanced intervention (biventricular pacemakers, left ventricular assist device, or transplantation)
tummy time: how to do it and frequency
Start by placing her belly-down on your chest or across your lap for a few minutes at a time so she gets accustomed to the position -do not perform after feeding (pressure on her full belly may cause her to spit up food) -perform when baby is awake and alert, such as after diaper change or nap frequency: -2 to 3 three min session daily newborn -gradually increase length of time to total of 20 mins a day
Virchow's triad
Stasis, hypercoagulability, endothelial damage that predispose individual to DVT and clots
bell's palsy management
Steroids (do not hesitate w/ steroid) - Should be started within 72 hours of symptoms onset - Prednisolone 50 mg PO daily (in 1 or 2 divided doses) x 10 days, or prednisone 60 mg PO daily for the first 5 days, and then tapering dose (by 10 mg/day) the next 5 days. Both regimens are equally effective The use of tear substitutes, lubricants, and eye protection (The ipsilateral eye should be patched and taped shut at night to avoid drying and infection) may be needed to reduce the risk of corneal drying and foreign-body exposure to the eye Valacyclovir (if herpes suspected) - Antiviral alone has no benefit over placebo (4), hence the use of antivirals as a monotherapy in new-onset Bell palsy is not recommended -Valacyclovir recommended over acyclovir d/t higher bioavailability - Valacyclovir 1000 mg PO TID x 7 days reassess 7-10 days
S4 heart sound
Stiff/hypertrophic ventricle (aortic stenosis, restrictive cardiomyopathy); hypertensive heart disease *S4 is always abnormal (may be considered a benign finding in an elderly pt w/ no other s/s) *TEN-nes-see
Bupropion Side effects
Stimulant effects (tachycardia, insomnia), headache, No sexual side effects. N/V/D LOWERS SEIZURE THRESHOLD.
Infectious Diarrhea work ups
Stool culture for: - Salmonella - Shigella - Campylobacter - Yersinia - E coli O157 Consider EIA for Shiga like toxin C difficile assay if hx abx use in last 3 mths Ova/parasite stool assay if diarrhea > 7 days or a/w hx travel or community outbreak If nausea prominent s/s: - add Norovirus/ Rotavirus/ Adenovirus Hx ingesting raw shellfish - culture for Vibrio
Acute Sinusitis most common bacteria
Streptococcus pneumoniae h influenzae m. catarrhalis
FDA Category X
Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience *risks outweigh the benefits.
The 3 commonly reported types of SUID (sudden unexpected infant death) include...
Sudden Infant death syndrome (SIDS) Unknown cause Accidental suffocation and strangulation in bed (ASSB)
Loop diuretic contraindication
Sulfa allergy (sulfonamide antibiotics share a common structural element w/ many nonantibiotic drugs, including thiazide and loop diuretics, sulfonylurea, etc) Gout
fifth disease tx < erythema infectiosum, Parvovirus B19>
Supportive Can use IV immunoglobulin with transient aplastic anemia crisis (usually only in immunocompromised/those with anemia already)
Metformin MOA
Suppresses hepatic glucose production (gluconeogenesis) Increases insulin receptor sensitivity (increases tissue glucose uptake)
Hirschprung's Disease Management
Surgery is the mainstay tx of choice to resect the affected portion or ostomy. gi rest follows
Hand Foot Mouth Disease Management
Symptomatic care - PO antihistamine - steroid (for lesion, 1-2 mg/kg in divided doses) - stay home - monitor dehydration (sore inside makes difficult to eat or drink) - pt edu (infx itself is not tx'ed; usually goes away on its own within about a wk)
Infectiouse Mononucleosis management
Symptomatic management Nonpharm: - avoid sports for at least 4 wks after the onset of symptoms and until they are asymptomatic - return to sensible amount of activities based on your energy lvl - hydrate - throat lozenge or spray for pharyngeal discomfort Pharm: - NSAID/tylenol for pain *corticosteroid and acyclovir not helpful
Parkinson's disease clinical features <parkinson s/s, symptoms>
Symptoms often subtle or attributed to aging Early sxs: - tremor - fatigue - anxiety and other mood sxs (apathy, depression) - orthostatic hypotension - constipation - loss of smell - progressive bradykinesia - difficulty walking - micrographia - facial masking - stooped posture Late sxs: - dysphagia (can cause aspiration and choking) - difficulty chewing Sxs (symptoms arise d/t dopamine deficiency): 1. tremor (slow 2-5 htz) 2. rigidity 3. bradykinesia/hopokinesia/akinesia 4. postural instability 5. festination (quick, short steps) 6. masked facies- decreased frequency of blinking 7. soft speech- monotonous tone w/ lack of inflection *NO WEAKNESS 8. dysfunction in other parts of brain beyond substantia nigra leads o depression, dementia, sleep disturbances, difficulty smelling 9. RLS 10. Autonomic symptoms (constipation, urinary difficulties, sexual dysfunction, sweating, orthostatic hypotension, dysphagia)
tinea capitis treatment
Systemic PO therapy is required; topical will not be sufficient. Trichophyton infx: - Griseofulvin for 6 to 8 weeks (pref 8 wks; more than 8 requires LFT, CBC for hepatic or hematologic) - Terbinafine for 2 to 4 weeks in children older than 4 Microsporum infx: - Griseofulvin 6-12 wks (pref 8 wks) *TOP therapy w/ selenium sulfide or povidine-iodine shampoo may help increase eradication rates but alone is not sufficient therapy. For children with tinea capitis due to Trichophyton species (excluding those with kerions), 1 week of terbinafine is effective *Give Griseofulvin w/ fatty food (peanut butter, ice cream) has better absorption w/ fatty food
acute bronchitis vs TB s/s <tuberculosis>
TB usually presents w/ hemoptysis, night sweats, fever
antidepressant choices in PEDS
TCA > 12 y/o SSRI > 18 y/o *(Fluoxetine > 8 y/o)* others > 8 y/o
CVA management <stroke, TIA, transient ischemic attack>
TIA first line: aspirin, Aggrenox, clopidogrel Acute CVA - immediate emergency department referral or specialist consultation -BP control -anticoag if ischemic - NPO until formal swallow evaluation done Use - ABCD2 score When pt is back from hospital - BP control within few days if HTN - ASA therapy - smoking cessation - blood sugar- screen for DM using A1C, oral glucose tolerance testing - cholesterol management if LDL > 100 mg - nutrition / exercise - sleep apnea- tx of sleep apnea improves outcome (CPAP) - TIA: mainstay is pharmacologic w/ antithrombotic agent (must be within 4.5 hr of stroke)
Microcytic Anemia causes
TICS T - Thalassemia - Iron deficiency - Chronic disease / inflammation (this can also be normocytic) - Sideroblastic anemia / bone marrow issues / ETOH abuse / TB drugs / lead/ chronic inflammation / chemo therapy - Thalassemias
wound: if < 3 Tetatnus Toxoid doses given, administer...
TIG + Td
pertussis diagnosis
TLDR: ask the pt "how long have you been coughing?" In the setting of a pertussis outbreak or known close contact with a confirmed case, the presence of a cough lasting ≥2 weeks is sufficient for clinical diagnosis (even in the absence of other symptoms). In non-outbreak settings, the choice of diagnostic tests (culture, polymerase chain reaction [PCR], serology) depends upon the duration of cough -For patients with less than two weeks of cough in whom there is clinical concern for pertussis, perform both culture and PCR for B. pertussis. The sensitivity of culture is highest during the first two weeks of illness. -For patients with two to four weeks of cough, perform both culture and PCR. The sensitivity of culture declines after the first two weeks, but PCR remains useful up to four weeks since it can detect nonviable organisms. Both tests should be performed since the accuracy of PCR as a stand-alone diagnostic test requires further study. Serology may be a useful alternative to culture in this setting once it has been standardized and more widely available. -For patients with more than four weeks of cough, only serology is useful.
OA 1st line pharm???:
TOP Diclofenac - Voltaren Gel - Pennsaid Patch
androgenic alopecia female 1st line tx
TOP Minoxidil
varicella infx tx
TOP antipruritic med Analgesic & anti-inflammatory med Antiviral (Acyclovir, Famciclovir, Valacyuclovir): - best to start within 24 hrs, still give if symptomatic. Antiviral may help reduce the risk of complications. Start within 72 hrs - We suggest not administering antiviral therapy for healthy children ≤12 years. . Varicella is typically a self-limited disease in this population. - We administer antiviral therapy to adults even if they were previously vaccinated. - recommend Valacyclovir (easier dosing, fewer administration) - Dosing: Valacyclovir adults (1 g TID x 7 days) children 20 mg/kg/dose TID x 5 days Varicella-Zoster ImmunoGlobulin / Varizig (is indicated for susceptible individuals after a significant exposure if they are ineligible for varicella vaccine prophylaxis, at high risk for severe infection and/or complications, and can receive immunoprophylaxis within 10 days of exposure) Varicella Vaccine if <= 5 days after exposure
HSV-2 vs TOP antiviral
TOP antiviral drug is of little clinical benefit to HSV-2
impetigo tx:
TOP if limited # of lesions Nonbullous (minor spread, treat 7 days; widespread, treat 10 days); bullous (treat 10 days) -***Mupirocin (Bactrboan) and retapamulin are 1st line tx -Mupirocin 2% TOP TID for 5-7 days and retapamulin applied BID for 5 days extensive impetigo and ecthyma -***systemic abx- cephalexin or dicloxacillin (effective against both staph and strep) -erythromycin and clindamycin may treat impetigo but s. aureus and GAS may become resistant -if only beta-hemolytic streptococci detected in extensive impetigo or ecythma, PO PCN preferred, limited strep impetigo may be treated w/ topical therapy if suspected MRSA impetigo -***Bactrim, clindamycin, or doxycycline -Fluoroquinolones should not be used to treat impetigo, as MRSA resistance to this class is widespread and resistance can develop on therapy.
TRUE OR FALSE: Most pts w/ IBS will exhibit normal lab findings.
TRUE
TRUE OR FALSE: steroid therapy raises risk of TB <tuberculosis>
TRUE
Transesophageal Echocardiograpm indication
TTE remains the initial test of choice for most pts requiring an echo. TEE is recommended during.. - suspected acute aortic pathology (e.g. dissection, transsection, intramural hematoma) - suspected prosthetic valuve dysfunction - suspected complications of endocarditis (eg fistula, abscess) - evaluation for left atrial/left artial atrial appendage thrombus in pt w/ afib/flutter to faciliate clinical decision making regarding anticoagulation, cardioversion, or ablation (cardioversion is not recommended w/ thrombus) - eluation of source of embolism in a young patient for hwom a TEE woul be performed i the TTE was normal
If >=3 tetatnus toxoid doses given, administer...
Td
If wound is clean and minor and last tetanus dose was > 10 yrs, administer...
Td
If wound is dirty or severe and last dose was > 5 yrs ago, administer...
Td
what vaccines are given during pregnancy
Tdap Influenza
pt reports ball of hair that fell out in shower, likely dx?
Telogen Effluvium
allylamine list
Terbinafine (Lamisil) naftifine (Naftin)
?Terbinafine vs Pediatric
Terbinafine safety not established in < 4 y/o
Tetracycline list
Tetracycline Minocycline Doxycycline Democlocycline Tigecycline
What are Ellipta inhalers?
The Ellipta from GlaxoSmithKline is their new platform inhalation device. It has dual strips inside the mechanism, which mix within the device on actuation (when you use the inhaler). The Ellipta differs from the current Diskus device, which only uses 1 inhalation strip. Is there an advantage to using the ELLIPTA device? Yes. Studies on ELLIPTA show that patients prefer it over the Diskus inhalers due to the ease of use, the dose-counter, and the feel and fit of the device. Which other Ellipta inhalers are on the market? In addition to Breo Ellipta (fluticasone furoate and vilanterol), Anoro Ellipta (umeclidinium and vilanterol) and Incruse Ellipta (umeclidinium) are available for the treatment of COPD. Another device, Arnuity Ellipta (fluticasone furoate), is available for the treatment of asthma.
Wells Criteria when to use
The Well's Criteria risk-stratifies pts for PE and provides an estimated pre-test probability. The provider can then choose what further testing is required for diagnosing PE. the original intent of this tool was to determine who was low risk enough to rule out testing w/ a d-dimer
Hidradenitis suppurativa Patho
The exact cause of hidradenitis suppurativa isn't known. It develops when hair follicles in the skin become blocked. Experts think it could be connected to hormones, inherited genes and immune system problems. Smoking, excess weight and metabolic syndrome also might play a role *The condition is not infectious or related to hygiene or the use of deodorant
PCOS tx:
The goal of treatment in PCOS depends on symptoms and patient's goals for fertility. weight loss (decreases insulin resistance, improves symptom) Metformin (increases insulin sensitivity, may normalize menstrual cycle) Spironolactone (may tx hirsuitism, but is teratogenic so contraception is required) PO contraceptive may regulate menstrual cycle
Low vs high dose dexamethasone test
The low-dose DSTs are standard screening tests to differentiate patients with CS of any cause from patients who do not have CS. The high-dose DSTs are not used to make the diagnosis of CS. They are used after the diagnosis of CS is made to distinguish patients with Cushing's disease (CS caused by pituitary hypersecretion of ACTH) from patients with ectopic ACTH syndrome (CS caused by nonpituitary ACTH-secreting tumors).
Otomycosis tx
The mainstay of therapy for otomycosis is meticulous cleaning of the ear canal and topical antifungal therapy. All debris and visible fungal elements must be removed by the clinician. -This should be done under direct vision with a cerumen loop or cotton swab. Binocular magnified vision facilitates removal of debris that is often present in the medial aspect of the ear canal, coating the tympanic membrane. Several topical medications are used to treat otomycosis, including antifungals, antiseptics, acidifying solutions, glucocorticoids, and drying agents [22]. Topical antifungals are considered first-line pharmacologic treatment (table 3) [23]. We use clotrimazole 1% solution, applied twice daily for 10 to 14 days. Clotrimazole has the greatest zone of inhibition for common fungi. After 10 to 14 days of topical antifungal therapy, we reassess the ear canal. If fungal elements are identified, the ear canal should again be meticulously cleaned and undergo a further 10- to 14-day course of topical antifungal with reassessment thereafter Oral antifungals may be used in refractory cases. Intravenous antifungals are reserved for patients suspected of having invasive otomycosis.
Diphtheria onset
The onset of respiratory diphtheria is insidious and begins after an incubation period of 2-5 days (range 1-10 days).
Cushing course after tx
The physical s/s of Cushing's syndrome resolve gradually over a period of 2-12 mths after effective cure of Cushing syndrome. HTN, osteoporosis and glucose intolerance improve but may not disappear.
MMR vs MMRV side efx profile
There is a small increased risk for febrile seizures after MMR and MMRV vaccines. MMRV results in 1 fewer injection but is a/w a higher risk for fever and febrile seizure 5-12 days after the 1st dose among children aged 12-23 mths (approximately 1 extra febrile seizure for every 2,300-2,600 MMRV vaccine doses).
rabies tx:
There is no known effective treatment for rabies, although the disease can be effectively prevented after recognized exposures using post-exposure rabies prophylaxis. 1. postexposure prophylaxis -Postexposure prophylaxis (PEP) consists of a dose of human rabies immune globulin (HRIG) + rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given again on days 3,+ 7, and 14. For people who have never been vaccinated against rabies previously, postexposure prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment. -People who have been previously vaccinated or are receiving preexposure vaccination for rabies should receive only vaccine. 2. symptomatic and supportive care
Polymyalgia Rheumatica Dx
There is no pathognomonic test or established diagnostic criteria for polymyalgia rheumatica. It is largely a diagnosis of exclusion. Following 4 must be met 1. Clinical manifestation: - proximally, bilaterally distributed aching, morning stiffness (last at least 30 mins or more) persisting for at least 2 wks. The stiffness involve 2/3 areas: neck or torso, shoulders or proximal regions of the arms, and lips or proximal aspects of the thighs 2. Diagnostics: - ESR elevated (> 40 mm/hr) - CRP elevated (especially CRP) - Creatine Kinase normal (b/c little damage to muscles) 3. Rapid resolution of s/s w/ low dose glucocorticoid (symptoms usually better within 3 days) 4. age 50 years or older at disease onset *Consider TSH, vit D, RF, ANA, anti-ccp
Thiazide vs osteoporis
Thiazide diuretic reduce Ca+ excretion by the kidneysand stimulate the osteoblasts. This helps build bone
TZD is short for...
Thiazolidenedione
Non-cardioselective beta blockers
Timolol Nadolol Propranolol Pindolol Labetalol Carvedilol Memorize!!!
Butenafine is prescribed to treat
Tinea infections (corporis, cruris, versicolor, pedis)
LAMA list (4)
Tiotropium (Spiriva) QD using Respmat or Handihaler Glycopyrrolate (Seebri) BID via Neohaler Aclidinium (Tudorza) BID via Pressair Umeclidinium (Incruse) QD via Ellipta
celiac disease dx:
Tissue transglutaminase (tTG)-IgA antibody is the single serologic testing of choice
Moderate Otitis Externa Tx:
Topical prep that is acidic and contains abx, antiseptic, and glucocorticoid - 1st line: Cipro HC, Cortisporin *Generally prefer Cipro HC; it is a/w fewer SE's than Cortisporin but is more costly *The abx should have coverage against Pseudomonas aeruginosa and Staphylococcus aureus
Alopecia Areata Totalis def
Total loss of hair on the scalp
Glaucoma surgical tx
Trabeculoplasty (opens trabecular meshwork) - is for open angle Iridotomy (punches hole in iris) - is or closed angle other laser txs - creates new channel Implants - shunt fluid out of anterior chamber by bypassing the system
Trepenomal vs Nontrepenomal
Treponemal tests detect antibody to T pallidum proteins Nontreponemal tests detect antibodies directed against lipoidal antigens, damaged host cells, and possibly from treponemes
Trichomoniasis cause
Trichomonas vaginalis (protozoa)
A saline wet prep of vaginal fluid w/ flagellated moving organisms visible under the micrscope is highly specific for the dx of...
Trichomoniasis vaginalis
True vs False Labor
True Labor → contractions w cervical dilation and shortening, increases in strength and frequency, increases w/ activity, show is present False labor → irregular contractions (not progressively stronger), w/out cervical change- does not increase in strength or frequency, stops or decreases w/ activity, show is not present
Neonatal Conjunctivitis w/ Chlamydia tx and prevention
Tx: (same as pneumonia infx): PO Erythromycin 50 mg/kg per day in 4 divided doses for 2 wks - if infx has not resolved, give 2nd course w/ same dose, same sched Prevention: - maternal screening prior to birth and appropriate tx - prophylaxis: not effective and not reocmmended
Neonatal Conjunctivitis w/ gonorrhea tx and prevention
Tx: - Ceftriaxone 25-50mg/kg (MAX 125 mg) IV/IM - admit to hospital and observed for response to therapy and for disseminated disease Prevention: - Erythromycin (0.5%) Ophthalmic ointment - Tetracycline drop (not available in US) - Silver Nitrate (not available in US) - can be deferred up to 1 hr after birth to facilitate infant-family attachment
Myasthenia gravis patho
Type II hypersensitivity - B cells produce autoantibodies that block acetylcholine receptors, preventing muscle contraction - Autoantibodies also activate complementary pathway that lead to muscle cell destruction -B cells may produce muscle specific receptor tyrosine kinase antibodies that target proteins in muscles that lead to destruction of muscle cells
first intention
Type of healing that occurs with primary union that is typical of an incision opened under ideal conditions; healing occurs from side to side, dead space has been eliminated, and the wound edges are accurately approximated
Measles s/s
Typically begins w/ prodromal period( 2-4 days, MAX 8 days) - HIGH fever (may spike to more than 104°), - Cough - Conjunctivitis - Coryza 2-3 days after symptoms begin: Koplik spots *Koplik spot FOLLOWS the prodromal period (pathognomonic of Rubeola; clustered, blue-white centered lesions on the buccal mucosa) 3-5 days after symptoms begin: measles rash appears on the face then spreads downward to the neck, trunk, arms, legs, and feet - exanthum lasts 4 days - may or may not be itchy - When the rash appears, a person's fever may spike to more than 104° Fahrenheit.
Seborrheic Dermatitis patho
UNCLEAR - linked w/ yeast Malessezia - possible immunologic abnormalities It is NOT due to - poor hygiene - alelrgy - does not harm the body
lichen planus cause
UNKNOWN CAUSE Patho: for unknown reason, healthy keratinocytes present antigens on MHC I -> cytotoxic T cells kill them while releasing cytokines which recruit more cytotoxic T cells to the scene -> damage to the surrounding tissue -> melanocytes release melanin (skin becomes hyperpigmented) -> damage extends beyond stratum basale and spinosum, reaches stratum granulosum which causes keratinocytes to increase in number and size (stratum grfanulosum become thicker = hypergranulosis) *can be triggered by specific medications
Fibromyalgia cause
UNKNOWN, problems w/ pain signal (decrease in serotonin which help dampen pain, and increase in susbtance P and nerve growth factor which worsen pain) may lead to hypersensitivty to pain (central sensitization) -central sensitization means it will affect wide range of things: how they sleep, how they think (negative feeling like depression and anxiety might amplify the sensitvity to pain
Herpes Lab work
USPSTF and CDC recommend against serologic testing for genital herpes because it is unclear how to counsel pts with a positive serologic test but not history of genital herpes. Herpes is also extremely common and mild so it is practical not to test for it unless severe. window of 2 wks- 6 mths after HSV to formation of detectable antibody
USPSTF ovarian cancer screening
USPSTF found evidence that current methods available to screen for ovarian cancer do not reduce mortality due to ovarian cancer
routine ophthalmology screening recommendation:
USPSTF: insufficient evidence to recommend routine screening in persons >= 65 y/o American Academy of Ophthalmology: complete eye exam q 1-2 yrs after 65 yrs
Cushing's tx
UTD: Optimal tx involves localization and complete removal of a corticotropin (ACTH)-secreting pituitary or ectopic tumor or cortisol-secreting adrenal tumor(s) If pituitary microadenoma (suppression at high-dose): confirm w MRI --> remove If adrenal adenoma (no suppression at either dose): confirm w CT --> remove
Addison/ Adrenal Insufficiency common causes
UTD: Prolonged administration of pharmacological doses of synthetic glucocorticoids is by far the most common cause of ACTH deficiency and consequent adrenal insufficiency Critical illness: subnormal corticosteroid production during critical illness in the absence of structural defects in the HPA axis has been termed "functional adrenal insufficiency" or "relative adrenal insufficiency". Primary Adrenal insufficiency: - cortex is damaged and can't produce enough adrenocortical hormones - most commonly the result of the body attacking itself (autoimmune disease) - other causes of adrenal gland failure may include: TB, infx of adrenal gland, adrenal gland cancer, bleeding into the adrenal gland - in underdeveloped areas, M. Tuberculosis infx is common cause Secondary adrenal insufficiency: - benign pituitary tumors, inflammation, and prior pituitary surgery are common causes of not producing enough pituitary hormone - mineralocorticoid production is not affected by too little ACTH.
Traveler's Diarrhea vs abx indication
UTD: We suggest not treating most cases of travelers' diarrhea with antibiotics. Abx tx is reasonable for travelers w/ severe diarrhea, which is characterized by fever and blood, pus, or mucus in the stool, or for travelers w/ diarrhea that substantially interferes w/ the purpose of travel. Antibiotic treatment can reduce the duration of travelers' diarrhea from several days to one or two days. AFP: those with diarrhea lasting 14 days or more should be tested for intestinal parasitic infection, and those who were treated with an antimicrobial within the preceding eight to 12 weeks should be tested for C. difficile infection.
UTI vs Prostatitis symptom
UTI will have no fever, chills, constitutional symptoms and prostatic tenderness on DRE Isolated UTI likely involve some bacterial contamination along prostatic duct, but prostatic contamination remain superficial w/o prostatic inflamation
When an infant is found to have tufts of fine dark hair on the sacrum, which tests is recommended?
Ultrasound of the sacrum
LABA/LAMA Combo list
Umeclidinium and Vilanterol (Anoro) QD using Ellipta Olodaterol and Tiotropium (Stiolto) QD using Respimat Indacaterol and Glycopyrrolate (Utibron) BID using Neohaler Formoterol and Glycopyrrolate) BID using Aerosphere
Commotio Cordis
Uncommon condition Trauma to chest when heart is vulnerable (at upstroke of T wave); is often lethal disruption of heart rhythm Ventricular fibrillation (VF) Treat like VF patient: CPR, defibrillation An example of such a condition a young athlete who tries to catch a baseball, but misses. The ball strikes the patient in the center of the chest and the patient collapses in cardiac arrest. common sports are baseball, lacrosse, hockey
Diphtheria tx
Untreated respiratory diphtheria usually lasts for 1 to 2 weeks, but complications can persist for months. Before treatment was available, the case-fatality rate was approximately 50%
Syphilis Dx
UpToDate: - Initially, treponemal test is favored by many laboratories as first test, especially those that perform relatively high volumes of syphilis testing, since automated treponemal-specific enzyme immunoassay (TP-EIA) testing for syphilis is less expensive than the nontreponemal rapid plasma reagin (RPR) test. Dr. Plato - initial RPR (nontreponemal serum screen) - if positive perform, treponemal *Methods that detect the organism directly are not generally available
osteoporosis Ca+ & vit D recommendation
UpToDate: - Calcium 1200 mg/day (total diet + supplement) - Vit D 800 IU/ day *Optimal intake of calcium and Vit D is uncertain. *most widely available Ca+ supplement are Calcium Carbonate and Calcium Citrate
Trichomoniasis diagnosis
UpToDate: NAAT (if available) when microscopy (LPF) is unavailable or unreliable (mobile unicellular protozoa w/ flagella and a large amount of WBC's) - while finding motile trichomonads on wet mount is diagnostic, they are identified < 70% of the time w/ active trichomoniasis infx making the NAAT preferred.
Traveler's diarrhea tx
UpToDate: We suggest not treating most cases of travelers' diarrhea with antibiotics. Antibiotic treatment is reasonable for travelers with severe diarrhea, which is characterized by fever and blood, pus, or mucus in the stool, or for travelers with diarrhea that substantially interferes with the purpose of travel. Antibiotic treatment can reduce the duration of travelers' diarrhea from several days to one or two days. UpToDate: In general, we use azithromycin or a fluoroquinolone. Fluoroquinolones had long been the first choice (effective against most enteropathogens), but the emergence of resistance to this drug class and increased awareness of adverse events make the risk-benefit assessment less clear. Trimethoprim-sulfamethoxazole (Bactrim, Septra) and doxycycline are no longer recommended because of the development of widespread resistance. UpToDate: fluoroquinolone to shorten course - 2-3 days therapy sufficient for the majority of travelers' diarrhea; a single dose of ciprofloxacin or norfloxacin may also be effective. - Ciprofloxacin 500 mg PO BID x 2-3 days; 750 mg single dose - Norfloaxcin 400 mg BID x 3 days - Levofloxacin (Levaquin)—500 mg - Ofloxacin (Floxin)—400 mg, usually relieves mild cases of traveler's diarrhea in less than 24 hours Azithromycin - preferred for pts w/ fever or dysentery (bloody or mucoid diarrhea), pregnant women, children (10 mg/kg/day up to a maximum dose of 500 mg for 3 days), and travelers (table 1) to locations, such as Southeast Asia (AFP: Thailand), where quinolone-resistant Campylobacter jejuni is a common cause - the most effective and practical dose (a single 1 g dose) causes nausea in some individuals. A 3-day course of 500 mg daily is also effective. AFP: Loperamide (Imodium A-D) 2-mg tablets PO two tabs initially, then one tab after each loose stool (maximum 24-hour dosage: 8 mg) - Antimotility agents can be used alone (ie, without abx) in mild to moderate travelers' diarrhea. - *may be taken if the pt does not have dysentery. Before beginning abx therapy, however, patients should first take a dose of loperamide to see if the antimotility agent stops the diarrhea. abx therapy should be deferred until it is clear that the diarrheal illness requires abx therapy, since dietary change and stress can cause transient GI upset. - The use of loperamide in dysentery has been controversial because of concerns about prolonging illness, but it is now considered safe when combined with an antibiotic
peptic ulcer dx
Upper GI endoscopy (most accurate dx test for PUD) - Endoscopy is costly, invasive, and recommended only for patients with "red flag" symptom -looks at esophagus and stomach with dye -NPO past midnight -NO: smoking, chewing gum, mints. -remove nicotine patch - smoking increases stomach motility which will affect test, as well as increases stomach secretions which increases chance of aspiration Urea breath test - Stop antibiotics, PPI, and bismuth for at least 4 weeks and PPIs for 1 week prior to testing because of high false-negative rates. Lab tests to consider: - CBC: Rule out anemia. - FOBT - LFT - Lipase - H. Pylori testing - If multiple/refractory ulcers: Consider fasting serum gastrin to rule out gastrinoma.
Bisphosphonate side effects
Upper GI tract irritation (dyspepsia, abdominal pain, dysphagia) - follow special administration instructions for patients Corrosive esophagitis (except zoledronate), nausea, diarrhea, osteonecrosis of the jaw, renal failure. Hypocalcemia
Asymptomatic Bacteriuria Screening method
Urine Culture - For example, screening for asymptomatic bacteriuria during pregnancy is done w/ a urine culture at 12 to 16 weeks of gestation or at the first prenatal visit AFP: Urine dipstick doesn't tell enough info- urine dipstick for leukocyte esterase will reliably identify pyuria but it is not specific for asymptomatic bacteriuria; dipstick for nitrites is also of limited usefulness b/c of infx w/ non-nitrite-producing organisms, the delay between collection and testing of the specimen, and insufficient time since the last voiding for nitrites to be produced at detectable lvls. The combination of the dipstick for leukocyte esterase and nitrites is more specific for asymptomatic bacteriuria than either test alone.
UTI: would you order urine culture for dx?
Urine cultures are recommended only for patients with suspected acute pyelonephritis; patients with symptoms that do not resolve or that recur within two to four weeks after the completion of treatment; and patients who present with atypical symptoms
uti dx
Urine dipstick aka rapid UA (Easy) - Nitrites and leukocyte esterase are the most accurate indicators of acute uncomplicated cystitis in symptomatic women (The dipstick test is most accurate for predicting UTI when positive for either leukocyte esterase or nitrite, with a sensitivity of 75 % and a specificity of 82 %. However, results of the dipstick test provide little useful info when the clinical hx is strongly suggestive of UTI, since even negative results for both tests do not reliably rule out infx in such cases. 5minconsult: Negative dipstick in the presence of high pretest probability does not rule out UTI.) UA (Leuks, Nitrite, WBC or Bacteria)
heat application
Used for chronic conditions to help relax and loosen tissues, and to stimulate blood flow to the area.
Isoniazid AE
Usually well tolerated - risk of hepatitis increases w/ age - peripheral neuropathy - rare: seeizures, granulocytosis, anemia, thrombocytopenia
Pernicious Anemia tx
V12 IM or deep SQ injection at an initial dose of 1000 mcg (1 mg) once/wk for 4 weeks, followed by 1000 mcg/ month
Wet AMD pharm tx
VEGF inhibitor (intravitreal vascular endothelial growth factor inhibitor) - bevacizumab - ranibizumab - aflibercept daily eye drop (vit C, vit E, lutein, zeaxanthin, zinc, copper)
Entresto is combo of...
Valsartan (ARB) and Sacubitril (Neprilysin inhibitor)
Cranial Nerve VIII
Vestibulocochlear
Eustachian tube dysfunction causes
Viral URI is the most common cause in children during the winter mths. Anatomy of eustachian tube: it is positioned more horizontal in children compared w/ adults, and the tube does not open regularly b/c opening of the eustachian tube is a function of active muscular contraction and the palatal muscles in younger children are not as well developed as they are in adults.
Erythema Multiforme can be precipitated by what?
Viral infections - Epstein-Barr - coxsackievirus - echovirus - varicella - mumps - poliovirus - hepatitis - cytomegalovirus - HIV - molluscum contagiosum virus Bacterial infections - Mycoplasma pneumoniae; - Treponema pallidum, - Mycobacterium tuberculosis - Gardnerella vaginalis Medications - NSAIDs - antibiotics, - penicillin - sulfonamides - antiepileptics Vaccines: - stronger association with HPV, MMR, and small pox vaccines - also a/w hepatitis B, meningococcal, pneumococcal, varicella, influenza, diphtheria-pertussis-tetanus, and Haemophilus influenzae Occupational exposures: herbicides (alachlor and butachlor), iodoacetonitrile
Diarrhea common pathogen
Viral: - Norovirus - Rotavirus (common in peds) Bacterial - Capylobacter - E. Coli - Salmonella - Shigella Parasitic - Cryptosporidium enteritis - Entamoeba histolytica - Giardia lamblia Stress, anxiety, etc
pernicious anemia is what type of anemia
Vit B12 deficiency
Newborn Vitamin supplements
Vit D 400 IU/day (decreases risk of rickets) - can be given as multivitamin infant supplement or vit D supplement - Breastmilk alone does not provide infants w/ an adequate intake of vit D
Dry AMD daily eye drop is composed of
Vitamin C, Vitamin E, lutein, zeaxanthin, zinc, copper
Norovirus vs Rotavirus
Vomiting is more prominent w/ norovirus infx. Norovirus is the most common viral cause of epidemic gastroenteritis worldwide; it can be acquired at any time of year. Rotavirus most commonly occurs in children between mths and 2 years of age. in temperate climates, it occurs in the fall and winter. In tropical climates, it occurs throughout the year.
Smoking Cessation Therapy 1st line
W/ few exceptions, the choice of a 1st line med depends on pt preference. UTD: For most patients, we suggest either varenicline OR a combination of 2 nicotine replacement (a patch plus a short-acting form such as the gum or lozenge) as 1st-line pharmacologic therapy. combination of 2 nicotine replacement products (All forms of NRT increase quit rate 50-70%. Combining long-acting maintenance w/ short-acting breakthrough NRTs is more effective than using any single method alone) e.g. a patch + short acting form such as gum or lozenge - If pt uses NRT, they CANNOT smoke (nicotine overdose) *for smokers who smoke 25+ cig/day, 4 mg dose gum is recommended *for smokers who smoke less than 25 cig/day, 2 mg dose gum is recommended *chew at least one piece of gum every one to two hours while awake and also whenever there is an urge to smoke *use up to 24 pieces of gum per day for 6 weeks., gradually reduce use over a second six weeks, for a total duration of three months.
Ginkgo Biloba and ginseng may interact w/ what med(s)?
Warfarin
otitis media with effusion tx
Watchful observation preferred - Generally spontaneously resolving condition except for children with hearing impairment, developemtnal delay, or specific conditions (such as cleft palate ) in whom OME is often persistent and needs to be addressed -po abx -po corticosteroid -tympanostomy if pharm doesn't work
cataract prevention
Wear sunglasses to protect the eye from UV light ARED 2 vitamin has mixed result Vit C may be helpful, but evidence is still mixed (minimum 300 mg/day)
Obstructive Sleep Apnea risk factors
Well defined risk factors -older age, over age 40 - large neck size - enlarged tonsils, - GERD -male gender -obesity -craniofacial and upper airway abnormalities Potential risk factors: - smoking - family hx of snoring or OSA - nasal congestion
Batteries stuck in esophagus: consideration
When batteries become lodged in the esophagus, they represent a medical emergency. Necrosis of the esophagus may occur due to liquefaction from the electrical current and may lead to ulceration within a few hours of ingestion and perforation as early as eight hours after ingestion [38,88,89]. Longer-term retention may lead to pressure necrosis and/or leakage of caustic material, with resultant tissue damage including perforation.
Abdominal Aortic Aneurysm
When the large blood vessel (aorta) that supplies blood to the abdomen, pelvis, and legs becomes abnormally large or balloons outward.
Shoulder Impingement cause
When the space between the bone on top of the shoulder (acromion) and the tendons of the rotator cuff rub against each other during arm elevation.
ADHD DSM-5 Criteria
Will be classified as... - Predominantly inattentive (inattention criteria met, hyperactivity/impulsivity criteria not met) - Predominantly hyperactive/impulsive (attention criteria not met, hyperactivity/impulsivity criteria met) - Combined presentation: both criteria met -6+ symptoms of either category -symptoms must be present before age 12 -Present in 2 or more settings -Clear evidence of impairment -s/s must not arise from other psychiatric conditions -DSM-5 is applicable to dx children AND adults
Carotenemia tx
With elimination of the intake of carotene-rich foods, serum carotene levels drop sharply within a week and the yellow discoloration of the skin gradually disappears over several weeks to months. Medications are not indicated for the treatment of diet-induced carotenemia
systemic lupus erythematosus management in pregnancy
Women who received glucocorticoids in pregnancy need higher doses of steroids in labor. Immunosuppressive medications not recommended during pregnancy. Efforts are aimed at reducing the risk of infection.
secondary intention definition
Wound closure in which the edges are separated; granulation tissue develops to fill the gap; and, finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention.
Alprazolam brand name
Xanax
Degludec + Liraglutide is called (brand)
Xultophy
First line contraceptive for PMDD
Yaz
Carotenemia PE
Yellow pigmentation of the skin that is more pronounced under artificial light. Yellow pigmentation often appears first on the tip of the nose, palms, soles, and nasolabial folds, extending gradually over the entire body. [17] However, the yellow pigmentation is most prominently displayed on the palms, soles, and nasolabial folds. The sclerae are always spared, which readily distinguishes carotenemia from jaundice; however, carotenemia occasionally may present with coloration of the palate. Note that the conjunctivae and oral mucosa are areas lacking stratum corneum.
hand foot mouth disease- can child go back to school with it?
Yes, except for when: - The child is not feeling well enough to participate in class or has a fever. - The teacher or child care provider feels he or she cannot take care of the child without compromising care for the other children in the class. Excessive drooling from mouth sores might be a problem that people find difficult to manage. - The child has many open blisters. It usually takes about 7 days for the blisters to dry up. - The child meets other exclusion criteria. Note: Exclusion from child care or school will not reduce the spread of hand, foot, and mouth disease because children can spread the virus even if they have no symptoms and the virus may be present in the stool for weeks after the symptoms are gone
azithromycin brand
Zithromax, Zmax, Z-pak
cetirizine brand name
Zyrtec
Irritable Bowel Syndrome def <IBS def>
a common condition of unknown cause with symptoms that can include abdominal pain w/ constipation and/or diarrhea that are relieved w/ BM
astigmatism
a condition in which the eye does not focus properly because of uneven curvatures of the cornea
trichotillomania def
a disorder characterized by the repeated pulling out of one's own hair
Cheilosis
a disorder of the lips characterized by crack-like sores at the corners of the mouth
JAMAEvidence
a guide to evidence-based medicine including tools for calculating health risks for different populations/disease states
Neurleptic Malignant Syndrome def
a life-threatening condition that may develop during tx w/ neuroleptic meds; 2/3 of cases develop within the first 2 wks of initiating therapy but can happen at any time during therapy. most likely to occur w/ first gen antipsychotics
Toxoplasmosis def
a parasite that is most commonly transmitted from pets to humans by contact with contaminated animal feces
Raynaud's disease
a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress
Dysmetria
a type of ataxia; inability to control the distance, power, and speed of a muscular action -as evidenced by lack of coordination in finger to nose exercise
UTI when to culture?
a urine culture is recommended for: - women w/ suspected acute pyelonephrotitis - women w/ syptoms that do not resolve or that recur within 2 to 4 wks after the completion of tx - women who present w/ atypical symptoms
Fludrocortisone SE
a/w s/s of Iatrogenic Cushing Syndrome -obesity -hyperglycemia and diabetes d/t increased gluconeogenesis and insulin resistance -HTN, osteoporosis, and increased risk of infx d/t excessive cortisol
Prenatal maternal depression VS infant head circumference
a/w smaller infant head circumference
Mittelschmerz def
abdominal pain that occurs midway through a menstrual cycle — about 14 days before your next menstrual period. In most cases, mittelschmerz doesn't require medical attention. Symptoms can include dull, cramplike, or sharp and sudden pain that's usually mild but in rare cases can be more severe. It usually lasts a few minutes to a few hours, but may last as long as a day or two.
hCG lab value for (+) pregnancy
above 25 mIU/mL
testicular torsion: most sensitive physical finding
absence of the cremasteric reflex (mostly in boys older than 30 mths)
Tinidazole use
abx that is used to treat certain types of vaginal infxs (*bacterial vaginosis, trichomoniasis*). Also used to treat certain types of parasite infections (*giardiasis, amebiasis*).
Bupropion has activating effect or sedating efx?
activating
Hep B vaccine: why is it necessary for infants
acts as a safety net, reducing the risk of getting the disease from moms or family members who may not know they are infected with hep B.
Interstitial Cystitis epidemiology
actual prevalence unknown d/t variability of diagnostic criteria majority of affected are women (10:1 rate) mean age of dx: 42-45 y/o
anagen effluvium cause
acute interruption of anagen phase (leadds into extensive hair loss w/o transition of follicles into catagen or telogen phase) -e.g. chemotherapy
Addison/ Adrenal Insufficiency clinical presentations
acute or chronic Acute: - main sign: shock - often have nonspecific s/s such as anorexia, N/V abdominal pain, weakness, fatigue, lethargy, fever, confusion, or coma Chronic primary s/s: - Often nonspecific, resulting in long delays in dx - *Fatigue*, wt loss, N/V, abdominal pain, *muscle and joint pain* - Specific: skin hyperpigmentation, postural hypotension, salt craving (hyperpigmentation occurs b/c more pre-pro-opiomelanocortin are produced to increase the amount of ACTH lvl but they can also be converted into Melanocyte-stimuatling hormone) - Common lab findings: *hyponatremia, hyperkalemia (due to lack of aldosterone), anemia* Chronic secondary s/s: - hyperpigmentation is NOT present b/c ACTH secretion is not increased - dehydration not present, and hypotension is less prominent - hyponatremia and volume expansion may be present d/t inappropriate increase in vasopressin secretion or action d/t cortisol deficiency - hyperkalemia not present b/c aldosterone is present - GI s/s less common - hypoglycemia more common in secondary adrenal insufficiency
high triglyceride increase risk of
acute pancreatitis
Panic disorder: class(es) of med used
acute: benzo long term: SSRI
phobic disorder: class(es) of med used
acute: beta blocker or BZD long term: SSRI MAOI, gabapentin
Lymphocyte function
adaptive immune response (by direct cell attack or via antibodies) - B lymphocyte, T lymphocyte
Panic disorder: benzo choice
adding clonazepam on top of an SSRI is suggested -dose: 0.25 to 0.5 mg qhs and increase by 0.25 to 0.5 mg q 3 days until sympatomc distress is improved.
fundal height: full bladder concern
additional 2/3 cm added
Mild Dehydration: rehydration amount
administer following liquid amt in small amt frequently (15-30 mins) -Children less than 2 years old: 50-100 mL of oral rehydration solution (ORS), after each evacuation, providing a volume similar to the assessed fluid loss (gastrointestinal and urinary) For children over 14 years old and adults: ensure at least 2 L per day and add one glass (200 mL) per each bowel movement
Byetta Rx sig
administered SQ BID 1 hour before meal
Most individuals first develop recurrent aphthous stomatitis during...
adolescence
Autosomal Dominant Polycystic Kidney Disease has symptoms that begin usually in what phase of life?
adulthood, but renal cysts may be present in childhood
HTN blood pressure goal
adults w/ confirmed HTN and CV disease, or 10 year ASCVD risk of 10% or more: - <130/80 mmHg CKD: - <130/80 Diabetes: - < 130/80 HFpEF: - < 130/80 HFrEF: - < 130/80 Kidney transplant - <130/80 PAD: - < 130/80 Stable ischemic heart disease: - <130/80
Reticulocyte normal range
adults: 0.5-2.5 % infants: 2-6 %
baker cyst cause
adults: often 2ndary to degenerative or inflammatory joint disease or joint injury, especially in older pts w/ knee pathology and possibly because knee/bursal communications increase in prevalence with age. *The most common knee disorders include osteoarthritis (OA), rheumatoid arthritis (RA), and meniscal tears. Among 3, rheumatoid arthritis is the mot common cause, according to Dr. Long LACHC. peds: popliteal cysts are usually a primary process, arising directly from the gastrocnemius semimembranosus bursa; they do not communicate w/ the joint space A valve-like effect between the knee joint space and the cyst, which is controlled by gastrocnemius-semimembranosus muscle changes with knee flexion and extension. This contributes to sequestration of synovial fluid in the popliteal fossa [11]. The communicating space is open in flexion, but the tense gastrocnemius-semimembranosus muscles close this pathway in extension. Negative intraarticular knee pressure during partial knee flexion (minus 6 mmHg), compared with a positive pressure (16 mmHg) during extension. These pressure changes help direct the synovial fluid flow from the suprapatellar bursa toward the knee during flexion and toward the cyst during extension [11]. Bursal pressure exceeds joint pressure during extension, but the flow of synovial fluid is blocked by the valve-like effect just described. Enlargement of the gastrocnemius-semimembranosus bursa from repeated small traumas of the bursa related to muscle contraction. Joint-cyst communication, which has been documented by cadaveric dissections, at the time of arthroscopy, and by injecting dye directly into these structures [2].
Myasthenia Gravis epidemiology
affected young women and older men
Subacute thyroiditis prognosis
after 6-8 wks, symptoms disappear
Acromioclavicular sprain symptoms
after the initial trauma, pts experience generalized shoulder tendernss and swelling over time, the athlete will complain of specific tenderness at the acromioclavicular joint that is worse in the evening and a stiff and sore shoulder when awakening. Popping and locking of the AC joint may occur. Pain is exacerbated w/ lifting or exercises such as wt training
cervix is not fully developed until
age 25
USPSTF prostate cancer screening
age 55- 69 annual or every other year, talk with patient about PSA based screening and make decision together If pt has high risk, start at age 40 yrs old If AA, make have aggressive cancer, so individualize it with the pt prostate-specific antigen (PSA) testing alone is the most appropriate test for screening. We suggest a screening interval of one to two years. For most patients, we offer screening up to age 70 years, stopping earlier if comorbidities limit life expectancy to less than 10 years.
Bioavailability of topical medications varies with
age and concentration
Polymyalgia Rheumatica age group
age over 50 y/o -peak incidence occur between 70-80 y/o
the most common cause of irreversible blindness in pts older than 65
age related macular degeneration
Infants vs Vitamin K
all newborns receive a vitamin K injection at birth to prevent vitamin K deficiency. Vitamin K aids in the coagulation pathway. Infants w/ vitamin K deficiency are at risk for hemorrhagic disease of the newborn, which is caused by a lack of VK reaching the fetus acroos the placenta, the low level of VK in breast milk, and low colonic bacterial synthesis. There is no need to supplement a breastfed infant w/ vitamin K
persistent eustachian tube dysfunction is related to
allergic reaction
Folate deficiency anemia is seen lot more in what kind of pts
almost always related to restricted diet for longer than 6 wks; alcoholic; pregnant mothers
Polymyalgia Rheumatica epidemiology
almost exclusively a disease of adults > 50 y/o (peak incidence of PMR between 70-80) PMR is 2x or 3x more common than giant cell arteritis and occurs in about 50% of pts w/ GCA.
Gonorrhea male discharge character
almost like semen thick whitish green discharge
Phenylephrine class
alpha 1 agonist
pleural effusion def
an abnormal amt of fluid within the pleural space
Panic Attack Diagnosis
an abrupt surge of intense fear or intense discomfort that reaches a peak within mins, and during which time 4/13 s/s occur: 1. palpitations, pounding heart, or accelerated heart rate 2. sweating 3. trembling or shaking 4. SOB 5. feelings of choking 6. chest pain or discomfort 7. nausea or abdominal distress 8. chills or heat sensation 10. paresthesia 11. derealization or depersonalization 12. fear of losing control or going crazy 13. fear of dying characterized by recurrent panic attacks and at least 1 month of either constant worry over having a panic atatck and/or maladaptive change in behavior related to attacks
Kaopectate moa
an oral, nonabsorbed medication that is used in the management of diarrhea. It works by adsorbing (binding) large numbers of bacteria and toxins and reducing the loss of water. Attapulgite reduces the number of bowel movements, improves the consistency of loose or watery stools, and relieves the gastrointestinal cramping that often is associated with diarrhea.
Sentinel event
an unexpected occurrence that results in death or serious physical or psychological injury, or the risk thereof -they include patient safety events that result in death, permanent harm, or severe temporary harm. Other events considered sentinel include suicide by a pt who is receiving care, tx, and services in a 24 hr staffed setting or within 72 hrs of discharge; unanticipated death of a full-term infant; discharge of an infant to the wrong family; hemolytic transfusion reactions involving administration of blood products w/ major blood group incompatibility; wrong site surgery; surgery on the wrong pt; and retained foreign body during surgery
Metronidazole is effective against
anaerobes including C. diff and protoza (amebiasis, giardisis, trichomoniasis)
Conjunctival pallor is an indication for...
anemia workup in elderly pts
Cheilosis is also known as...
angular cheilitis perleche
how to check for ACL laxity
anterior drawer test OR Lachman test
Infliximab class
anti TNF alpha
Sucralfate (Carafate) moa
anti-ulcer med that is not greatly absorbed into the body that works mainly in the lining of the stomach by sticking to ulcer sites and protecting them from acids, enzymes, and bile salts.
scopolamine moa
anticholinergic/ muscarinic antagonist
General Anxiety Disorder first line:
antidepressant as first line (SSRI, SNRI, TCA) -Paxil and Lexapro FDA approved SSRI -SNRI: Effexor, Cymbalta Benzo for immediate relief pregabalin buspirone hydroxyzine 2nd gen antipsychotic (quetiapine, olanzapine, risperidone)
Simethicone MOA
antiflatulent- decreases the surface tension of gas bubbles, causing them to combine into larger bubbles in the digestive tract, thereby helping you to pass trapped bubbles of intestinal gas via burping or flatulence *no convincing evidence noted
candida diaper dermatitis treatment
antifungal cream/ointment applied to the diaper area beneath the barrier ointment two to three times a day until the rash resolves - OTC: Nystatin, Clotrimazoler (Lotrimin), Miconazole - Rx: Ketoconazole (Nizoral), econazole Diflucan OI QD or BID for two weeks can be effective (if TOP tx fails) *combo of TOP corticosteroid and antifungal cream is not recommended ( both contain TOP coprticosteroid that are too potent for ifnant skin)
meclizine moa
antihistamine that suppresses the vasodepressor response to histamine while only slightly inhibiting acetylcholine
Atropine uses
antispasmodic: relaxes GI tract and bladder antidote for cholinergic agonists blocks respiratory tract secretions prior to surgery increase heart rate in pts w/ bradycardia decreases "death rattle" in dying patients (clears secretion)
Antidepressant Withdrawal Syndrome s/s
anxiety, depression, mood swings, agitation, mania, irrritability, confusion, paranoia, suicidal ideation N/V, cramps, diarrhea, loss appetite excessive sweating sleep changes (difficulty sleeping, vivid night mares) Balance (dizziness, lightheadedness) Control of movements (tremors, RLS, uneven gait, diffculty coordinating speech) Strange sensation (pain or numbneess; hypersensitivty to sound, tinnitis, "brain-zaps" feeling of electric shock to your head How to distinguish discontinuation symptoms from relapse - discontinuation symptoms emerge within days to wks of stopping the meds or lowering the dose, whereas relapse symptoms develop later and more gradually - discontinuation symptoms often include physical complaints that aren't commonly found in depression, such as dizziness, flulike symptoms, and abnormal sensations - Discontinuation symptoms disappear quickly if you take a dose of the antidepressant, while drug treatment of depression itself takes wks to work - discontinuation symptoms resolve as the body reeadjusts, while recurrent depression continues and may get worse.
Combined Oral contraceptive absolute contraindication
any conditions present or past that increase the risk of blood clotting smoking >= 35 y/o any conditions that increases the risk of stroke, including migraine headaches w/ aura inflammation and/or acute infx of the liver w/ elevated LFT (estrogen is contraindicated) known or suspected cardiovascular disease known or suspected pregnancy undiagnosed genital bleeding breast, endometrial, or ovarian cancer (any estrogen-dependent cancer) < 21 days postpartum d/t increased risk of VTE. Risk of VTE is still elevated in breastfeeding women until ~42 days postpartum. After 42 days postpartum, there are no restrictions for use specific to postpartum VTE risk.
bouchard node
any of the abnormal enlargements seen at the proximal interphalangeal joints in people with osteoarthritis
fundal height can be used during
anytime by 12 weeks
testicular torsion vs torsion of appendix testis clinical finding
appendix testis torsion: testis as a whole is not tender; small hard tender nodule noted; blue dot sign (blue palpable nodule/discolaration palpable on the upper pole of the testis)
Scopolamine: application education
apply it 4 hours before the trip to be effective
When does ovulation occur
around day 14
Benzo AE
arrhythmia CNS depression Hypotension
BNP moa
arterial and venous dilation enhanced natriesis (Na excretion) and diuresis suppress RAAS and SNS
theophylline is used when..
as a adjunctive therapy when inhaled steroids are unable to control symptoms, when other add-on drugs, such as LABA or leukotriene modifiers are unable to provide control sometimes used off-label for the tx of obstructive sleep apnea
tummy time: when to do it
as soon as newborn is home;
Bell's palsy how to differentiate upper neuron vs facial nerve damage (which is indicative of bell's palsy)
ask them to frown, wrinkle his forehead, and close his eyes shut - if facial nerve damage only, both upper and lower area will be paralyzed or weak - if upper motor neuron only (as in stroke), pt will be able to squint and wrinkle his forehead but not frown ALSO, ask them to recall - facial nerve damage: no effx on memory - upper motor neuron: may effect memory
Cluster headache are characterized by
at least 5 attacks of severe unilateral orbital supraorbital or temporal pain that lasts 15 mins to 180 mins w/ frequency of 8 per dayto one every other day and accompanied by restlessness or agitation, conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, forehead and facial sweating or flushign, aural fullness, miosis, and/or ptosis
Bupropion (Wellbutrin) purpose
atypical antidepressant and smoking cessation
if pus negative for bacterium, consider what...
atypical mycobacterium
Sjogren Syndrome def
autoimmune disease that attacks the glands that produce saliva and tears
CCB vs HFrEF
avoid CCB (except Amlodipine and Felodipine) since they provide no functional or mortality benefit and some first gen agents may worsen outcomes *Amlodipine and Felodipine appear to be safe and well tolerated in pts w/ HFrEF and can be used for tx of HTN or angina. However, ACEi or BB, which improve survival among pts w/ HFrEF, should be given first in pts w/ HTN, and BB should be given first in pts w/ angina or afib*
Celexa vs QT prolongation
avoid doses greater than 40 mg/d; can prolong QT interval
ingestion of what food makes urine pink/red
beet and rhubarb and Phenazopyridine (AZO)
visit schedule for pregnant mother
before 28th wk: monthly between 28 to 36 wk: biweekly between 36 to 40 wk: weekly 40 to birth: twice a week
Tic disorders are most severe during..
before puberty (10-12) during periods of anxiety, excitement, or exhaustion
fasting glucose screening frequency
beginning at age 45, once every 3 yrs (earlier in high-risk groups) USPSTF: 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.
Baker cyst def
benign mass formed at the knee joint by distention of a bursa with excess synovial fluid resulting from chronic irritation
fishtail uvula
benign variant- where uvula is split into 2 sections
Fenofibrate effect
best for lowering triglycerides
testicular torsion dx
best initial test-testicular doppler ultrasound (demonstrates reduced blood flow to testicle) gold standard-Radionuclide scan
Live attenuated flu vaccine: target age
between 2-50 y/o
pregnant mom: when to get Td
between 29-36 wk gestation
For people without diabetes, the normal range for the hemoglobin A1c level is...
between 4 and 5.6 %
between 12 and 16 wks, the uterus fundus will be at what level
between symphis pubis and umbilicus
Thiazolidinedione MOA (TZD)
bind to nuclear receptors in adipose and muscle tissue to increase insulin sensitivity
TZD MOA
binds to nuclear receptors in adipose tissue and muscle to increase insulin sensitivity
Leukotriene Receptor Antagonists moa
binds with high affinity to the cysLT1 receptor which inhibits the actions of LTD4 which *blocks the inflammatory pathway* *this is asthma controller, not rescue *is not first line, if ICS available
auspitz sign def
bleeding that occurs after psoriasis scales have been removed - occurs b/c the capillaries run very close to the surface of the skin under a psoriasis lesion, and removing the scale essentially pulls the tops off the capillaries, causing bleeding. Also found in other scaling disorders such as actinic keratoses.
Neonatal Conjunctivitis w/ gonorrhea complication
blindness
Finasteride MOA
block the conversion of testosterone to DHT by inhibiting the enzyme 5-alpha reductase (The action of DHT is primarily responsible for the enlargement of the prostate gland. The maximum reduction in prostate size (20% reduction) may take up to 6 mths of therapy. However, improvement in s/s is seen only in men w/ very enlarged prostates (> 40 g).
bartholin gland cyst
blockage of one or both of the Bartholin glands, causing inflammation and tenderness
Naltrexone MOA
blocks opioid receptors - blocks euphoric effx of ETOH - blocks feelings of intoxication
estrogen in COC increase risk of
blood clots strokes MI
how do you dry the wet cast
blow dry w/ low heat hair dryer
TCA Side Effects
blurred vision, urinary retenion, constipation, dry mouth
In America, most cases of drowning happen in...
bodies of freshwater - boys are 4 times more likely than girls to drown - infants likely to drown in bathtubs
heberden node
bony lump on the terminal phalanx of the fingers in osteoarthritis
stillborn def
born dead after 20th gestational week
Prozac vs Lexapro
both are SSRI; Lexapro preferred d/t milder SE
High risk population for drowning
boys under age 4 or between age 15-19 have the highest rate of drowning
COC may increase the risk of ___________ cancer but decrease the risk of _________________ cancer.
breast, ovarian, cervical (slightly for cervical) endometrial (COC lowers risk of endometrial cancer by 30%)
clicking noise during breast feeding- what does it mean?
breastfeeding is quiet. Swallowing noises are normal, but clicking noises should prompt assessmen for improper latch. The mother should check positioning and sucking. If the baby is clicking, tell the moher o use her index finger o pull the baby's chin down so the baby's lower lip is outside. The infant should have the entire nipple and mos of the areola inside the mouth.
squamous cell carcinoma would fluoresce what color under wood lamp
bright red
mupirocin target
broad-specturm activity against many gram-positive bacteria and certain gram-negative bacteria in vitro - high level of activity against staphylococci and streptococci and against certain gram-negative bacteria, including Haemophilus influenzae and Neisseria gonorrhoeae, but was much less active against most gram-negative bacilli an anaerobes
Otitis Media with Effusion dx <OME>
bubbles, air fluid level, opacity of the tympanic membrane No acute signs of symptoms of infection (bulging, marked erythema of the tympanic membrane, ear pain, fever) Weber test lateralizes to affected ear for an ear with effusion. insufflation w/ pneumatic otoscopy demonstrates decreased eardrum mobility - TM does not move with AOM and OME The child w/ OME with not have... - Otalgia - Otorrhea - s/s systemic infx
Symbicort is combination of which meds?
budesonide (ICS) and formoterol (LABA)
staph impetigo
bullae w/ clear border lesions - "pure skin"
which antidepressants have fewer sexual SE
bupropion and Mirtazapine
When to refer child to ophthalmologist?
by age 6, both eyes should be 20/20, if not at least 20/30 either eye by age 6, refer to ophthalmologist
baker cyst dx
can be PE alone - most prominent w/ pt standing and the knee fully extended (*easier to visualize with standing up; difficult to visualize laying down) - Foucher's sign: cyst may soften or disappear on flexion to 45 degrees as the tension on the cyst is relieved -The knee should also be examined with the patient lying supine and the knee put through full RoM from full extension to at least 90 degrees of flexion to confirm these findings and to adequately examine the knee joint for associated pathology. Imaging studies -can be performed in some pts, particularly when there is diagnostic uncertainty and when another condition is suspected. However, imaging is usually not required. - US and plain radiography (MRI as well)
Herpangina s/s
can be asymptomatic onset w/ abrupt high fever (102-104 F). Seizures may accompany the onset of fever. older children: may complain of malaise, headache, sore throat, dysphagia, and abdominal pain young adults: fever (96%), sore throat (96%), headache (72%), pain/stiffness of neck (72%), etc -Among young adults requiring hospitalization for herpangina, 57 % had neck stiffness, 80 % had a positive Kernig sign, and 49 % had cervical adenitis. throat reveals hyeremia and yellow/greyish white papulovesciular lesions - *Little involvement of anterior 2/3 of mouth (THIS IS KEY)* - the areas most frequently involved are the anterior pillars of the fauces, soft palate, tonsils, and uvula. - Very occasionally, a lesion may be seen on the hard palate, tongue, or buccal mucosa. The number of lesions varies but is usually less than 10 -The lesions begin as papules that undergo the vesiculation in 24 hours. The vesicles usually measure 1-2 mm in diameter and are surrounded by an areola of erythema. After approximately 24 hours, the vesicles rupture, leaving 3-4 mm in diameter, shallow, yellow/grayish ulcerations with a rim of intense erythema In children, there are usually no other physical findings.
traveler's diarrhea causes:
can be bacterial, parasite, or viral -E coli -Campylobacter jejuni and shigella -Giardiasis
hCG level can be detected when
can be detected by a blood test about 11 days after conception and about 12-14 days after conception by a urine test.
when can Naltrexone be started for Alcoholism
can be initaited while the individual is still drinking
Vitamin B12 anemia severity...
can be severe w/ hct as low as 10-15 %
Effect of Malaria on pregnancy
can cause premature birth, miscarriage, and stillbirth
rubeola complications
can damage lungs (pneumonia), intestines (diarrhea), and brain (encephalitis) bacterial superinfection (can suppress immune system for up to 6 wks ) Subacute Sclerosing Panencephalitis
NAAT use
can detect HIV infection in 7-28 days
tummy time: importance
can help your baby develop strong neck and shoulder muscles and promote motor skills also prevent the back of your baby's head from developing flat spots (positional plagiocephaly)
Pregnancy and travel contraindication
can travel safely until 36th wk gestation (most commercial airlines allow pregnant travelers to fly until 36th wk; some limit international travel earlier in pregnancy; some require documentation of gestational age; refer to the specific airline) highest obstetric complications noted during the 1st and 3rd trimesters. *most cruise lines restric t travel beyond 28th wks, some as early as 24 wks. *avoid activities at high altitude unless trained for and accustomed to such activities.
Zofran is indicated for
cancer-related nausea and vomiting (chemotherapy, radiation, surgery).
fluoroquinolon vs pregnancy
category C; no adquate studies, use only if clearly needed
Mittelschmerz cause
cause is unknown; it is believed that the fluid/blood that is released from the ovary irritate the lining of the abdominal cavity, causing sudden pain. The pain goes away soon after the egg is released or once the body absorbs the fluid or blood (14-36 hrs approx) many women never experience painful ovulation. some women, however, have mid-cycle pain q mthly and can deterine by the pain that they are ovulating
splinter hemorrhage may be due to
caused by physical trauma or injury to the nail bed that damages the capillaries and allows small amounts of blood to flow *or septic emboli / vegatation emboli of infective endocarditis
corticosteroid efx on bone
causes osteoporosis, bone degeneration
1st gen cephalosporin list
cefazolin (Ancef), cephalexin (Keflex) - activity agaisnt Gram positive cocci bacteria (such as Group A strep, S aureus) - not effective against beta-lactamase producing strains and MRSA - poor anaerobic coverage
primary teeth eruption time
central incisors (at ~6 mo), lateral incisors, first molars, canines complete by 30 - 36 mths
hypertrophic cardiomyopathy history
check family history (this is a familial disease)
Warfarin INR frequency if consistently stable
check q 2-4 wks
leukoplakia cause
chewing tobacco, heavy smoking, alcohol use *if hairy leukoplakia, may be s/s EPV infx, immunocomprise, or AIDS
chickenpox rash characteristic vs other rashes (like rubella)
chickenpox rash is intensely pruritic chickepox rash is vesicle on erythematous base that ulcerate and heal (they can get infected, leading to superinfection) rash typically starts on the trunk and then spreads outward, eventually covering the entire body including scalp usually whole thing resolves within 1 wk
ADHD: if parenting problem, how to spin it positively?
child feels more comfortable at home and he is more himself at home AND this can be helped with some guidance
meningitis vaccine schedule
child should get his first shot at age 11 to 12. He'll need a booster at age 16. *Catch-up: Age 13-15 years: 1 dose now and booster at age 16-18 years (minimum interval: 8 weeks) *Catch-up: age 16-18: 1 dose *The vaccine is recommended for kids who are younger than 11 if they have special risks for meningitis.
neurofibromatosis typically starts during what time of life
childhood
Hematuria and pyuria without bacteria may indicate
chlamydia, gonorrhea, viral infx, or less commonly, TB
Population based healthcare
choose a common condition that lends itself to a systems approach identify the pts in the practice w/ the condition choose measurable outcomes that reflect the best evidence based medical practice regularly measure outcomes and try to improve them
chronic bronchitis def
chronic productive cough lasting 3 mths during 2 consecutive yrs, after all causes of chronic cough have been excluded
Hypothyropidism most common cause
chronic thyroiditis (Hashimoto's thyroiditis)
Rhinitis medicamentosa is due to
chronic use (>3 days) of nasal decongestant
COPD predisposing factors
cigarette smoking occupational environmental or atmospheric pollutants genetic factor: alpha 1-antitrypsin deficiency recurrent or chronic lower respiratory infections or disease age
Cataract surgery pt education
clients go home almost immediately after this procedure in 2 to 3 hrs. Unless a large incision is required as a result of eye complicaitons, the procedure can be performed w/o sutures, which reduces the risk of eye discomfort. Eye patch may be worn for first 24 hrs on the affected eye There may be some discomfort, btu pain should be relieved w/ OTC analgesics
aphthous stomatitis diagnostic criteria
clinical, based on hx and PE Hx: - May experience prodrome of burning sensation of oral mucosa 2 to 48 hours prior to appearance of ulcers - Patients typically complain of oral ulcerations, which are painful and exacerbated by movement of the mouth. Exacerbation may also be reported with certain foods (hot, spicy, acidic, or carbonated foods or drinks) - Ask about ulcerative lesions of other anatomic areas, family history, prior history of aphthous ulcers (3) and new medications prior to onset of ulcers (1). PE: - Round or ovoid ulcerations generally <10 mm in size; covered with a grayish-white pseudomembrane surrounded by an erythematous halo - Ulcers are typically found in the buccal or lip mucosa, ventral tongue, soft palate, or oral vestibule; rarely on the roof of the mouth or lips - Evaluate for signs of secondary infection: elevated temperature, increased surrounding edema, or pus drainage.
PEDS iv solution to give for emergent iv therapy
colloid (5% albumin) or crystalloid (normal saline or ringer lactate)
gold stardard test for UC and Crohn's
colonoscopy
testicular torsion: comfirmativev diagnostic testing
color doppler testing (will show absence of blood flow: absence of color on reading, except the artifacts)
Older Americans Act
committed the government to providing Native Americans and elderly Americans with adequate income and medical care including transportation, foood, legal assistance, home health, and adult day care established in 1965 to provide improved access to services for older adults. in 1978, the OAA was amended to establish additional support services for Native Americans, including community services
Sulfonylurea AE's
common: - N/V/D - hypoglycemia (d/t increased insulin lvl and sensitivity) - wt gain (d/t increased insulin lvl and sensitivity) rare: - serious dermatological reactions
Gout pt education
complete clinical remission often requires many mths to several yrs to achieve, d/t slow reduction in the body monosodium urate crystal burden that has accumulated in most pts -diet (Avoid fatty, hig purine/red meat) -wt reduction -alcohol
Impetigo Expected Course
complete resolution 7/10 days w/ tx
Misoprostol indication
complex, high risk pts, who require chronic NSAID use for other conditions -Misoprostol mimics Prostaglandin and protects the gastric lining (provides gastric buffer)
Weber test lateralization to bad ear result
conductive loss otitis media serous otitis media ceruminosis TM perforation
antiparietal cell antibody is used to..
confirm a dx of pernicious anemia
Toxoplasmosis dx
congenital infx confirmed by persistently (+) IgG and IgM Ab titers in the infant, ophthalmologic, auditory, neurologic exam w/LP and head CT Maternal serum IgM, IgG can also be drawn
Meninigococcal vaccine schedule
conjugate (ACWY) - 2 doses IM 11-12 y/o, 16-23 booster *Catch-up: Age 13-15 years: 1 dose now and booster at age 16-18 years (minimum interval: 8 weeks) *Catch-up: age 16-18: 1 dose *The vaccine is recommended for kids who are younger than 11 if they have special risks for meningitis. *adults: 1 dose MenACWY and revaccinate every 5 years if risk remains Serogroup B - 2 doses IM 1-6 mths apart - given to children > 10 y/o who have increased risk of meningococcal infx (e.g. anatomic or functional asplenia, SCD, compmplent deficiency, exposed to meningococcal outbreak)
Rotator Cuff Tendonitis tx
conservative: no above shoulder activity, avoid sleep w/ arm overhead or ADD w/ IR???, decrease pain (positioning, modalities, rest), ROM, strengthen below shoulder, occ based training. post-op:PROM-> AROM (0-6 wks), pain (ice to heat), isometric->isotonic strengthening below shoulder (6 wks), work mod
why not given NSAID w/ anticoagulant
considered as double trouble for Afib pts using PO anticoagulants and NSAID together increases the risk for major bleeding and stroke in pts w/ AF
A common adverse effect of topical bacitracin and gramicidin is
contact dermatitis.
Hand Foot Mouth Disease risk factors
contact w/ oral, fecal, or respiratory secretions of infected people (highly contagious) may be transmitted through vesicle fluid
Metoclopramide vs PEDS
contraindicated in pediatric
Pepto Bismol vs peds
contraindicated in pediatric b/c contains salicylate
acute bronchitis: defining feature is...
cough that lasts more than 5 days (but less than 3 wks)) - Fever, or other systemic symptoms, are rare in patients with acute bronchitis (These findings, in addition to cough and sputum production, should raise suspicion for influenza or pneumonia) - On physical examination, signs of parenchymal consolidation such as dullness to percussion, decreased or bronchial breath sounds, rales, egophony, or signs of pleural inflammation such as a pleural rub suggest that disease extends beyond the bronchi, and chest imaging should be considered. (See 'Chest radiograph' below.)
Potential food that may increase INR
cranberry grapefruit black licorice garlic ETOH
strep impetigo appearance
crusty honeycomb - "dirty skin"
diphtheria dx
culture of C. diphtheriae from respiratory tract secretions or cutaneous lesions and a positive toxin assay
Nagele's rule
cycle = 28 days: - 1st day of last period + 1 yr - 3 mths + 7 days cycle = 21 days: - do not add the 7 days cycle = 35 days - add 14 days instead of 7 days
pediatric migraine preventative tx
cyproheptadine if cannot swallow pills (noted success w/ younger children) topiramate - only preventative approved by FDA for 12- 17 yr old
UTi include which 2 general conditions
cystitis (infx of bladder/ lower urinary tract) pyelonephritis (infx of the kidney/upper urinary tract)
menstrual cycle follicular phase: what happens
day 1- 13, hormones stimulate egg cells in ovaries to grow and mature in sack-like structure called follicle
kawasaki disease -def -cause -patho -epidemiology
def: vasculitis in coronaries, also affects any large/medium sized vessels as well cause: unknown, may be autoimmune, epidemiological features point to the role of infection and genetic predisposition. patho: endothelial membrane of vessels damaged -> exposes the underlying collagen and tissue factors in tunica media -> increased risk of coagulation, increased risk of ischemia, artery walls become weak because fibrin (stiffer, less elastic, can't gntly stretch) which develops to bulges (aneurysms) like coronary aneurysms epidemiology: most common- children < 5 yrs (boys) self limited, resolves in 6-8 wks (w/ or w/o tx, but 20-25 % risk of heart complications if not tx'ed)
Meniere's disease def and epidemiology
def: increased endolymph; tinnitus, vertigo, sensorineural hearing loss epidemiology (UTD): MD may occur at any age, but symptoms typically begin between the ages of 20 - 40 years. Meniere syndrome in children is most often associated with congenital malformations of the inner ear, and in adults it may be caused by acquired otologic disease. The incidence of MD is difficult to determine because of the lack of widely accepted diagnostic criteria but ranges from 10 to 150 per 100,000 persons. Among patients with MD, bilateral disease occurs in 10 to 50 percent of patients.
Legal Blindness
defined as a best corrected vision of 20/200 or less or a visual field less than 20 degrees (tunnel vision)
Giant cell arteritis dx
definitive dx is biopsy clinical manifestation dx: - claudication from chewing, intense pain radiating up
Prenatal maternal depression a/w what risks?
delayed fetal growth (monitor child as they grow) preterm delivery behavioral changes in offspring
Alpha Glucosidase Inhibitor MOA
delays breakdown of carb in intestines by inhibiting alpha glucosidase (breaks down carbs) *must be taken right before meal b/c it acts locally in the gut
Lewy Body Dementia s/s
dementia 1st in early stage later stage parkinsonism *compared to delirium, fluctuating episodic deficits of attention and alertness w/o identifiable cause points to LBD
ABORTION IS LEGAL UNTIL
depends on state law -CA: legal at and before wk 24
how frequently should a diabetic change diabetes glucose sensor
depends on the brand -CGM sensor q 3-10 days depending on the brand
Varicocele Tx:
depends on the size no strict criteria in place that dictates surgical intervention Subclinical or Grade I: no tx, reassure pt Grade II or III and size < 20% difference: observe and monitor; refer to urology if pt is concerned about fertility Grade II or III and >20% size difference: refer to urology to discuss possible surgical intervention *Refer for surgical correction if testis atrophied or pt concerned/complain of infertility
common initial presentation of type 1 diabetes
diabetic ketoacidosis
The leading cause of blindness in the western hemisphere
diabetic retinopathy
Interstitial Cystitis diagnostic
diagnosis of exclusion 1. urinalysis w/ microscopy 2. postvoid Residual Vole by either straight cath or US 3. urine c/s
Meniere's Dx
diagnostic criteria: - 2 episodes of spontaneous vertigo lasting 20 mins minimum -documentation of hearing loss on audiometric test -aural s/s (reduced/distorted hearing, tinnitus, fullness)
Acute diarrhea def
diarrhea < 2 weeks
Chronic diarrhea def
diarrhea > 4 weeks
Magnesium Hydroxide SE
diarrhea, hyporeflexia, hypotension, cardiac arrest, muscle weakness, respiratory depression, stomach cramps
pulse pressure def
difference between systolic and diastolic pressure
yeast infx Rx:
diflucan 150 mg CAP once
digoxin toxicity: labs to order
digoxin lvl K+, Mg+, Ca+ Creatinine Serial EKG
varicocele cause:
dilation of the pampiniform plexus of spermatic veins; generally left sided first appears at puberty and may become larger over time
Lomotil is composed of
diphenoxylate/atropine
testicular torsion management
direct referral to urology for correction (necrosis of testis is likely after 10-12 hrs) manual detorsion if surgery is not performed within 6 hrs
Molluscum contagiosum: how do you get it
direct skin-to-skin contact
Syphilis discharge character and sxs
discharge typically not present 1st stage: - painless ulcer in the genital, rectum or mouth where T. spirochete first made contact 2nd stage (disseminated stage): 6-12 wks after infx - generalized lyphadenopathy - non-pruritic maculopapular rash (spirochetes attach and infx endothelial cells in small capillaries near skin; starts in trunk then to extremities and all over the body) may be pustular, papulosquamous, condyloma lata, resolves within wks to mths 3rd stage (dormant, asymptomatic; spirochetes dormant in capillaries of organs and tissues) - early phase (typically occurs within a yr of infx): spirochetes circulating in blood causing sxs - late latent (spirochetes stay within the tiny capillaries of various body organs and tissues) 4th stage (tertiary stage) type 4 hypersensitivity d/t T cells combating spirochetes - various organs damaged (heart, brain, liver, joint, testes)
pediatric vs antiemetic
discouraged in uncomplicated vomiting anticholinergic and antihistamine can cause hallucinations and convulsions in children and decrease alertness do not use in children under 12 y/o of age EXCEPT - promethazine, dimenhydrinate- avoid in children < 2 y/o - ondansetron- approved for use in children < 4 y/o
COPD definition
disease characterized by presence of airflow obstruction d/t chronic bronchitis or emphysema (pt typically presents w/ both)
meds that increase gout risk are..
diuretics and low dose aspirin
honey vs pediatric age
do not give before 1 y/o - reasoning: Clostridium bacteria that cause infant botulism usually thrive in soil and dust. They also can contaminate some foods — honey, in particular. Infant botulism can cause muscle weakness, with signs like poor sucking, a weak cry, constipation, and decreased muscle tone (floppiness).
sulfonamide contraindications
do not use in <= 2 mth old
bactrim vs pregnancy
do not use unless absolute need -Sulfa drug interferes w/ folic metabolism
aminoglycoside vs pregnancy/lactation
do not use unless benefit outweigh the risks
most common animal bites is
dog bites (accounts for 90% of animal bites)
child weight gain pattern in first year
double by 6 mths triple by 12 mths
Pulsus Paradoxus
drop in blood pressure >10 mmHg with inspiration
depression tx goal
drop of >= 5 pts after 4-6 wks of antidepressant is considered "adequate" and f/o in another 4 weeks is needed -drop of 2-4 pts from baseline is considered "probably inadequate" and often warrants an increase in antidepressant dose -drop of 1 pt or no change is "inadequate" and requires increase in dose, augmentation, switch in med, CBT, or psychiatric consultation *Ultimate goal is to reduce PHQ9 score to < 5 pts. - pts who achieve this goal enter into the continuation phase of tx - pts who do not achieve this goal remain in acute phase tx and require some alteration in tx
Bacterial meningitis is transitted via...
droplets
Lomotil side effects
dry mouth, dry eyes/blurred vision, urinary retention, constipation, tachycardia, drowsiness, respiratory depression
DVT dx
duplex ultrasound-preferred venography-definitive
ACTH stimulation test is used for...
dx of Addison's
f/u schedule for HF pt after discharge
early f/u within 7-14 days and early telephone f/u within 3 days
Meniere's disease s/s
early phase: intermittent attacks of vertigo lasting from mins to hours (20 mins to 3 hrs) often a/w N/V 4 main s/s may occur simultaneously -dizziness described as spinning vertigo -low frequency sensorineural hearing loss -tinnitus -feeling of fullness in affected ear
Amytrophic Lateral Sclerosis s/s
early s/s: - asymmetric hand weakness- > dropping of objects - cramping of upper extremities (common) - dysarthria, dysphagia, dysphonia develop later Atrophy- > decreased strength, decreased muscle bulk, abnormal tone -> fasciculations (also leads to weakness and w/c use) Late s/s: - respiratory weakness -> dyspnea -> respiratory infection - recurrent bouts of cough, fever, chill -> pneumonia
What is pulmonary rehab
education, functional assessment, nutrition counseling, and follow-up to reinforce behavioral techniques for change exercise training component (>30 minutes 3x weekly for 6-8 weeks) has been shown to improve endurance, flexibility, and upper and lower body strength
tetracycline spectrum
effective against a wide variety of gram-positive and gram-negative bacteria - most gram - posti
Second Generation Antipsychotics work on...
effective on both positive and negative symptoms
Vitamin B12 can be confirmed w/ what lab
elevated Homocysteine and Methylmalonic Acid
Developmental Surveillance definition
eliciting and attending to parental concerns, obtaining a relevant developmental history, making accurate and informative observations of children, and sharing opinions and concerns with other relevant professionals. *Pediatricians often use age-appropriate developmental checklists to record milestones during preventive care visits as part of developmental surveillance.
Bacterial Diarrhea tx of choice
empiric tx: - Cipro, Levaquin
Community Acquirerd Pneumonia dx
empirical dx: fever/hypothermia, tachypnea, cough w/ or w/o sputum, dyspnea, chest discomfort, sweats or rigors (or both), bronchial breath sounds or inspiratory crackles on chest auscultation imaging: CXR is diagnostic (parenchymal opacity)
American with Disabilities Act
ensures access to employment and the community for individuals with mental or physical disabilities
Consolidated Omnibus Budget Reconciliation Act
ensures that individuals can maintain their insurance in the event of a "qualifying event" such as loss of a job or death of the covered employee
Emergency Medical Treatment and Active Labor Act (EMTALA)
ensures that pts are not d/c'ed from the Emergency Department for economic reasons
most common cause of acute scrotal pain in prepubertal boys is
epididymitis
diverticulitis cause
erosion of the lumen from high pressures CAUSES INFLAMMATION lodged fecalith can cause inflammation but is less common *diverticulitis is a complication of diverticulosis
diphtheria management
erythromycin
what cause endometrium to thicken
estrogen and progesterone
Excedrin complication
even though it is typically use for treatment of headache (effective for tension headache), it may cause rebound headache
Acne follow up
every 3-4 mths
Symbicort typical administration schedule
every day 2 puffs in morning and 2 puffs in evening
# of diapers: breastfeeding vs formula
exclusive breastfeeding has more diapers than those who drink formula
Iatrogenic Cushing's syndrome is usually caused by...
exogenous corticosteroid
derealization
experiences of unreality or detachment with respect to surroundings
Baker cyst epidemiology
fairly common in adults and children -They tend to occur in adults from ages 35 to 70 -The prevalence increases with age, possibly because knee/bursal communications increase in prevalence with age. There is no consistent difference in frequency between the sexes.
The large majority of ectopic pregnancies occur within...
fallopian tube
What is Braxton-Hicks Contractions?
false contractions, painless, irregular, and usually relieved by walking occurs commonly during 3rd trimester
Presbyopia
farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
Norovirus transmission
fecal-oral, fecal aerosolization, formites *Norovirus is not killed by alcohol or standard cleaning agents. Therefore, wash hand with soap and water. Clean contaminated environmental surfaces with bleach.
if abnormal fundal height noted, order..
fetal US to determine estimated fetal wt
Missed Abortion definition
fetal demise prior to 20 wks gestation w/ retention of the fetus inside the uterus. presents w/ adequate growth and absent fetal heart tones or an empty gestational sac on routine monitoring The mother usually presents w/ decreased or absent fetal movement. Cervix is closed on exam. Medical management w/ misoprostol or a D&C can be performed, depending on the pt's preference
kick count: abnormal reading
fewer than three fetal kicks within an hour or cessation of fetal movement for 12 hours indicates the need for evaluation
Raynaud's disease affect which areas?
fingers toes nose ears lips
Meconium passes within...
first 48 hrs of life -premature child can take a little longer
Meconium will pass within
first 48 hrs of life -premature neonates can take a little longer
hcg will peak at
first 8-11 weeks of pregnancy and then will decline and level off for the remainder of the pregnancy.
Norovirus diagnosis
first exclude bacterial cause, then can be differentiated from bacterial gastroenteritis
Stable angina treatment
first line: - BB (reduce both HR and contractility) CCB - used in combo w/ BB if initial tx w/ BB is not successful or as a substitute for BB -long acting diltiazem, verapamil , amlodipine, or felodipine preferred Nitroglycerine - 1st line - SL administration, consider oral or dermal prepartions to improve exercise tolerance Treat underlying coronary artery disease - ASA - cholesterol lowering drugs may need revascularization
Polymyalgia Rheumatica Management
first line: initial prednisone PO 15 mg/day (initial dose may be variable; lower dose of 7.5 mg to 10 mg/day may suffice in smaller pt; 20 mg or more may be appropriate in pt w/ severe aching and stiffness) -if symptoms are not significantly improved within 1 week of therapy, escalate prednisone dose to 20 mg/day F/u in 1-2 wk by phone or email to see if tx is working. a formal return visit at 4-8 wks should be arranged in order to 1) confirm resolution of symptoms and 2) outline a plan for glucocorticoid tapering -taper 2.5 mg/day every 2-4 wks Duration of therapy: in most pts, PMR runs a self-limited course, and prednisone can eventually be dc'ed. Tx can be stopped after 1 to 2 yrs. Other pt requires longer period at stable doses of 5 mg/day or less. Nonpharm: - exercise /diet to strengthen muscle and bones
Cushing Syndrome Dx:
first, check for exogenous source - Low index of suspicion for Cushing Syndrome, perform 1 of the following tests - High index of suspicion, perform 2 or 3 of the following tests TESTS: 1. 24 hr urine free cortisol (2 measurements) - normal <40-50 ug/d 2. late night blood or saliva cortisol (2 measurements) - normal: < 3-4 nmol/L (0.1-0.15 ug/dL) - the result should be unequivocally increased (threefold above the upper limit of normal for the assay) 3. Overnight Dexamethasone Suppression Test (low dose of Dexamethasone suppresses ACTH production, should lower cortisol lvls) - if positive, determine the cause of endogenous cortisol production - normal < 1.8 ug/dL (50 nmol/L) if following ACTH are found... - low- probable adrenal adenoma or carcinoma - high- probable cushing disease or ectopic ACTH production (inject dexamethasone, see what happens) *Some centers use the longer low-dose DST (2 mg/day for 48 hours) as an initial test
Amenorrhea lab work up
first, hCG urine next, FSH, LH, TSH to evaluate common endocrine causes of 2ndary amenorrhea
Acute Otitis Media tx of choice <AOM>
first- "Watchful waiting" for 2 days- b/c viral is common Second: abx course: Pediatric - High-dose Amoxicillin (80 -90 mg/kg/day) is the tx of choice for acute Otitis media if not allergic to PCN - use Augmentin instead if they used amoxicillin or had conjunctivitis in past 30 days (conjunctivitis may indicate h. influenzae to which augmentin is effective) *adult: - Augmentin 875 mg/125 mg PO BID - Amoxicillin 500 mg PO TID or 875 mg PO BID - Cefdinir 300 mg PO BID or 600 mg PO QD - Doxycycline 100 mg PO BID Third: Tympanic membrane tubes
Parkinson's posture
flexed posture bowed head trunk bent forward kyphotic back hands held in front of the body elbow, hips, knees flexed lateral tilting of the trunk
Roseola s/s
flu-like symptoms extremely high fever up to 104 F/ 40 C (can trigger febrile seizure), typically lasts 3-5, resolves quickly Maculopapular rash develops AFTER fever resolves (begins on trunk then spread to the face or extremities)
Pediarix should be followed w/ what vaccines
followed with 4th and 5th doses of DTaP and a 4th dose of IPV at appropriate ages.
Fluoroquinolone vs food
food interaction noted, take 2 hrs before or after meals *also, efx reduced significantly by concomitant use of milk, antacids, Fe prep, Al/Mg/Ca+/Fe/Zn
what decreases INR
food: -Vit K rich food (just has to consistent amount of food, not avoid it all together) OTC meds: - antacids, antihistamines Prescribed meds: -PCN -barbiturates -rifampin -OCP
ASQ-3 is used for
for developmental and behavioral screening for birth to 8 years old parents fill the form out
PEDS screening tool is used for...
for developmental and behavioral screening for birth to 8 years old parents fill the form out
Addison's workup
for most pts - 8 am cortisol - plasma ACTH - high dose 50 mcg ACTH stimulation test
Lyme disease AB can persist how long
for several years
spinous process tenderness suggests...
fracture of dislocation if preceded by trauma, underlying infection, or arthritis
sulfonamide vs allergic reaction
frequent occurrence, limit usage
sulfonamide vs drug resistance
frequent occurrence, limit usage
Orbital cellulitis types
from least to to worst: - preseptal cellulitis -orbital cellulitis -subperiosteal abscess -orbital abscess -cavernous sinus thrombosis
herpes- avoid sex how long
from prodrom to 48 hours after symptoms resolve (pt contagious)
f a woman with a distressing sexual problem greatly desires interventions, what do you provide?
full eval of physical and pyschiatric disorders (e.g. depression) nonpharmacological intervention first, reduce stress and fatigue, increase quality time with partners, and refer to sex therapist, or couples counselor (highly effective) then pharmacological intervention (wellbutrin is often the first choice)
Cochrane Databse of Systematic Reviews provides...
full text of systematic reviews
Pediatric Constipation most common cause
functional constipation is responsible for 95% of cases *organic causes are responsible for less than 5% of cases
Child sexual abuse s/s
functional somatic symptoms such as injuries in their genital area, infx, blood in their underwear regression w/ thumb sucking or bedwetting eating disorders excessively talking sexual acts
cold testicle is indicative of...
gangrene
Gastroesophageal reflux vs infants
gastroesophageal reflux is common in infants partly b/c of a decreased resting tone of the lower esophageal sphincter. Reflux may be considered physiological and does not require tx unless it is accompanied by poor wt gain or significant infant discomfort. Nevertheless, reflux is a common source of parental concern, creating demand for antireflux formulas thickened w/ added rice starch.
buspirone use
generalized anxiety disorder "i always get anxious if the BUS will be on time so i take buspirone)
fluoroquinolone AE
generally well tolerated but... *- high affinity for cartilage and tendons- risk of tendon rupture and tendonitis, especially in older persons* - contraindicated in children, adolescents, pregnant women, lactation - phototoxicity - transient increase in liver enzymes - QT prolongation
acute otitis media pediatric risk factors:
genetic predisposition - Eustachian Tube Dysfunction - Allergic Tendencies Bottle feeding (1st 3 mths) (breastmilk contains lactoferrin, oligosaccharide and surface immunoglobulin A that inhibit bacterial colonization) (sucking generates negative pressure) Incorrect posture while breastfeeding Underlying pathology -unimpaired cleft palate parental smoking large family/attending daycare immunocompromised states
Molluscum contagiosum: when to tx
genital area: must tx promptly immunocompetent children w/ molluscum contagiosum tx is optional
Gonorrhea typical presentation in male
genital gonoccocal infx are more likely to be symptomatic in men than in women (but still many are asymptomatic) when syptomatic - urethritis w/ dysuria and copious purulent discharge -acute unilateral epididymitis w/ testicular pain and swelling are possible complication
Macrolide AE
gi distress common (N/V/D) (especially Erythromycin) Ototoxicity, cholestatic jaundice QT w/ prolongation (risk of torsades de pointes)
What does Vitamin A do for Measles
given for young children and severely malnourished, boosts antibody response and decreases risk of complications
Infective endocarditis prophylaxis criteria
given to high-risk pts w/ structural heart disease prior to dental, skin, or respiratory procedures - prosthetic heart valves - cardiac valve repairs using prosthetic material - hx infective endocarditis unrepaired cyanotic congenital heart lesion - repaired congenital lesion w/ resdiaul shunts - valvular regurgitation in the setting of a transplanted heart
OVID Medline
gives access to both pubmed and medline
RBC cast suggests...
glomerulonephritis - warrants referral to nephrology
Corynebacterium Diphtheriae is gram + or -?
gram +
1st Gen cephalosporin has no activity against
gram negatives (some activity against E. Coli, Proteus, Klebsiella) MRSA Enterococcus
infective endocarditis common pathogens
gram positive bacteria such as Strep, S. aureus, Enterococci
Macrolide covers what bacterium
gram positive cocci (except enterococci), Staph Aureus (gram positive cocci), Strep pygenes (gram positive cocci), and atypical bacteria (i.e. mycoplasma, chlamydia)
Bacterial Vaginosis Gold Standard dx
gram stain
Chronic pain duration
greater than 3 monthstuberculosis
Trosseau's sign
hand spasm when bp cuff inflated
Carbon Monoxide toxicity s/s
headache, dizziness, nausea
cromolyn sodium common SE
headache, irritable N/V, stomach pain muscle pain rash
Women w/ PCOS are at higher risk for...
heart disease - risk of heart attack is 4-7 x greater in women w/ PCOS. HTN Elevated LDL and decreased HDL Endometrial cancer (Irregular menstrual periods and the lack of ovulation cause women to produce the hormone estrogen, but not progesterone. Without progesterone, the endometrium becomes thick, which can cause heavy or irregular bleeding. Over time, this can lead to endometrial hyperplasia and cancer)
Magnesium Hydroxide use
heartburn relief, reduce stomach acid, laxative to relieve occasional constipation (increases water in the intestines which may induce bowel movements)
in liver, Alkaline Phosphatase function?
helps break down proteins in the body
SGLT2 elimination
hepatic, then renal
Herpes on trunk, extremities, and head is called.
herpes gladiatorum
transfusion hgb threshold
hgb < 7 g/dL is a commonly used threshold for transfusion. - however, transfusion may be indicated at higher lvls if the pt is symptomatic or has a comorbid condition such as CAD.
most common cause of ear infx is
hib and strep
gestational hypertension def
high blood pressure that develops after 20 weeks of pregnancy. -no excess protein or s/s organ damage -some may develop preeclampsia
chronic hypertension def (in pregnant mom)
high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy.
Pneumonia high risk
high risk: - chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure) - chronic lung diseaes (including asthma tx'ed w/ high dose, oral corticosteroids), - diabetes - cerebrospinal fluid leak - cochlear implant - SCD and other hemoglobinophaties - anatmic or functional asplenia - congenital or acquired immunodeficiency - HIV infx - chronic renal failure - nephrotic syndrome - malignant neoplasms - leukemias - lymphomas - hodgkin diseaes - other diseases a/w tx w/ immunosuppressive drugs or radiation therapy - solid organ transplantation - multiple myeloma - chronic liver disease - alcoholism
Mycoplasma pneumoniae dx
histologicall by cold gglutinin EIA (most common test low cost) PCR (most rapid and effective, used in hospital often, expensive)
Ectopic Pregnancy risk factors
history of infertility, salpingitis (PID), ruptured appendix, prior tubal surgery, history of in-vitro fertilization, use of IUD
Prolactin
hormone produced by anterior pituitary, stimulates milk production
bartholin gland cyst tx
hot compresses and sitz baths 3 tims a day if mild or moderate if severe (large lesions that are clearly infected or persist after conservative measures for 2 weaks), PO abx to cover mixed flora
peptic ulcer pain duration and characteristics
hours visceral, burning, epigastric, aggravated/relief w/ food, antacids, normal ECG
Biliary disease duration and characteristics
hours visceral, epigastric, interscapular colic, occurs after meals
varicella-zoster virus is also called
human alphaherpesvirus 3 (HHV-3)
flu vaccine, be careful in pts w/...
hx GBS w/in 6 wks of a previous vaccine dose live is contraindicated in -pregnancy -immunodeficient individuals *egg allergy is no longer a contraindication to flu vaccine
post-lumbar puncture pt education
hydration caffeine restv
Raynaud Disease swelling, tingling, and pain is due to...
hyperemia (rubor) that happens when the blood rushes back to involved areas
Swan neck deformity
hyperextension of PIP joint and flexion of DIP joint - usually seen w/ rheumatoid arthritis
Loperamide side effects
hyperglycemia, (GI) abdominal pain, nausea, vomiting, xerostomia (Neurologic) Dizziness, somnolence, respiratory depression, constipation
farsightedness AKA
hyperopia
Preeclampsia def
hypertension develops after 20 weeks of pregnancy, and is associated with signs of damage to other organ systems, including the kidneys, liver, blood or brain
PTU use
hyperthyroidism
in male pt who reports that they have to sit to urinate, suspect...
hypospodias as potential cause
The most likely cause of seizures in adolescents and young adults are...
idiopathic disease, trauma, and substance abuse
flu vaccine sched
if first time, 2 doses then annually (if 6 mths or older) normal folks: annual
on pills, when to use emergency contraceptive?
if had unprotected sex in previous 7 days and missed 2 or more pills in the first week of the pack
cervical mucus fluid test
if like raw eggwhite stretchy and slippery, pt likely fertile if just wet/watery, still fertile but not as much
fluid volume replacement amount
if mild to moderate, 1-2 L isotonic crystalloid via ORS to restore tissue perfusion, continued until euvolemic
low sex drive of SSRI, how to address this concern?
if patient compliance may become an issue because of this specific sexual SE, switch from SSRI to bupropion (may improve sex drive and is sometimes prescribed for HSDD)
Warfarin INR frequency if single out-of-range INR noted
if patient has stable INR and has a single out-of-range INR equal to or less than 0.5 below or above therapeutic INR (2 to 3), experts suggest continuing current warfarin dose; retest INR within 1 to 2 weeks
meningitis vaccine *booster* schedule:
if vaccinated after age 7, booster every 5 years if vaccinated between age 2 and 7, booster after 3 yrs then every 5 yrs CDC recommends a booster dose for all teens who received the first dose before their 16th birthday. The booster dose provides the best protection during the ages when teens are at highest risk. Teens who receive their first MenACWY vaccine dose at or after age 16 years do not need a booster dose.
subclinical HPV dx
if visualization of wart not possible, perform Vinegar (acetic acid) solution test (will turn infected genital area white), PAP smear, HPV DNA test (done on collected or biopsied cells)
Neuroleptic Malignant Syndrome management
immediate d/c of antipsychotic dantrolene to reduce muscle contraction supportive care *no further tx w/ 1st gen antipsychotic, switch pt to 2nd gen (lower NMS risk)
rule these out before ruling in ADHD
impaired vision hearing problems lead poisoning anemia hyperthyroidism
Nexplanon method of administration
implant in upper arm, equally effective as IUD (99.9% effective)
PCN allergy ensues in what time
in 30 mins to 24 hours
Raynaud phenomenon occurs where
in hands and feet as a result of exposure to cold, vibration, and stress
hypospodias vs circumcision: relationship
in pts w/ hypospodias, circumcision should not be done b/c skin may be used later for repair
FENA calculation is used when...
in the evaluation of acute kidney failure in the context of low urine output.
25-hydroxyvitamin D def
inactive form of vitamin D, made in the liver from cholecalciferol
Otitis Media with Effusion patho <OME>
incompletely understood, appears to be a multifactorial condition that can result from a variety of inciting events that converge on a common pathway of inflammation, effusion, and tissue hyperplasia otitis media with effusion can occur after acute otitis media
Ovarian Cancer risk factors
increased age (most develop after menopause) Family hx Obesity- BMI >30 have increased risk Nulliparity or parity after age 35 yrs Use of fertility drugs Hormone replacement therapy PO Contraceptives Diet- high fat a/w higher rates
physiological anemia of pregnancy: cause
increased plasma volume druing pregnancy compared to RBC production
spironolactone BBW
increased risk of both benign and malignant tumors
Aldosterone efx on bicarb and H+
increases serum HCO3- (increases pH) decreases serum H+
Aldosterone efx on Na+ and K+
increases serum Na+ decreases serum K+
Incretin mimetic (GLP-1 receptor agonist) MOA
incretin-mimetic, analog of GLP-1 hormone, activates receptors for GLP-1 - Increases glucose-dependent insulin secretion - Decreases postprandial glucagon, - Slows gastric emptying - Suppresses appetite
Norovirus incubation period and duration
incubation: 24-48 hrs duration: 24-72 hours
What does a positive D-Dimer mean?
indicate the presence of an abnormally high level of fibrin degradation products. It indicates that there may be significant blood clot (thrombus) formation and breakdown in the body, but it does not tell the location or cause. An elevated D-dimer does not always indicate the presence of a clot b/c a number of other factors can cause an increased lvl. Elevated lvls may be seen in conditions in which fibrin is formed and then broken down, such as recent surgery, trauma, infection, heart attack, and some cancers or conditions in which fibrin is not cleared normally, such as liver disease. Therefore, D-dimer is typically not used to rule in VTE in hospitalized patients (inpatient setting). it should only be used to r/o deep vein thrombosis (DVT), not to confirm a dx.
how to test for rh factor
indirect Coombs test( indirect coombs tests for AB in serum vs. direct which tests for AB on cell surfaces)
indrect coombs vs direct coombs
indirect coombs tests for AB in serum vs. direct which tests for AB on cell surfaces -indirect can be used for
Bowel Movement frequency
infant: 3-4 stools/day first week of life -many healthy BREASTFED infants go several days or longer without a bowel movement. Infancy and toddler: 2 stool/day preschool to adult: once a day or once every other day
PEDS screening tool age group
infants and children up to 8 y/o
Herpangina epidemiology
infants and children, particularly those younger than 5 to 7 yrs. -occasionally occurs in adolescents and adults summer and early fall, similar to other clinical syndromes caused by Coxsackie enterovirus
infective endocarditis vs glomerulonephritis
infective endocarditis can lead to glomerulonephritis due to antigen-antibody complex depositing in kidneys
Polymyalgia Rheumatica pain originates from...
inflamed bursae and tendons, not from the joints themselves -> this creates referred pain
Acute gastroenteritis: def
inflammation and/or irritation of the digestive tract that can cause N/V, diarrhea, and/or abdominal pain that lasts less than 14 days
pleurisy (also known as pleuritic) def
inflammation of the visceral and parietal pleura causing chest pain
Gideon provides...
information on epidemiology and dx tool for infectious disease
DPP-4 inhibitor MOA
inhibitits DPP-4 which metabolizes Incretin. Elevated incretin lvl will increase postprandial insulin release (lower postprandial plasma glucose) * little or no efx on fasting plasma glucose
Entresto MOA
inhibits neprilysin from degrading vasoactive peptides AND blocks the vasoconstrictive effx of angiotensin II
Neprilynsin inhibitor MOA
inhibits neprilysin which increases lvls of natriuretic peptides, bradykinin, and adrenomedullin, thus resulting in natriuresis and vasodilatation.
Disulfiram MOA
inhibits the enzyme Acetaldehyde Dehydrogenase - leads to buildup opresef Acetaldehyde *causes hangover immediately after consumption of ETOH
Digoxin Overdose s/s
initial s/s: GI-related (anorexia, N/V, abdominal pain) others are arrhythmias, confusion, and visual changes (yellowish green tinged -colored vision, scotomas)
COPD tx for group C
initial therapy: LAMA (Tiotropium) - due to the reduced exacerbation rate associated with LAMA therapy compared to LABA therapy If further exacerbation: LAMA + LABA (preferred) OR LABA + ICS (i.e. Fluticasone-salmeterol)
low haptoglobin is indicative of
intravascular hemolysis
Trosseau's sign diagnostic
ionized Ca+ lvl will diferentiate true hypocalcemia from fictitious hypocalcemia and does not necessitate drawing an albumin lvl
Atrovent is composed of
ipratropium bromide
Lead poisoning can present w/ what anemia
iron deficiency anemia
celecoxib vs other NSAIDs
is selective COX-2 inhibitor, has reduced AE relative to ASA and NSAID (thus less GI efx) *is the only slective COX-2 inhibitor available
activating efx of some antidepressant is dangerous b/c...
it may increase the risk of suicide (activating efx take efx quickly)
use of rear facing car safety seat is recommended because..
it protects child's neck and spine
aminoglycoside is considered as one of the most dangerous abx b/c
it's a/w significant nephrotoxicity, ototoxicity, and neuromuscular blockade
reproducible chest pain means...
it's probably not acute coronary syndrome -Reproducible chest wall tenderness (CWT) on palpation of the thorax, where the maximum pain sensation is referred, is generally considered to be associated with a benign musculoskeletal cause and may help to rule out ACS in absence of additional examinations (ECG, laboratory tests, radiographic testing).
Hydroxyzine vs geriatric
its clearance decreases w/ advanced age, so be careful
plantar fasciitis diagnostics
lab work not helpful
Normal vaginal flora
lactobacillus, E. coli, GBS
Scopus is...
large abstract and citation database of peer-reviewed literature w/ biometric tools
G6PD deficiency s/s
largely asymptomatic until oxidative stress occurs jaundice dark tea-colored urine back pain (kidney damage) anemic symptoms (fatigue, tachycardia, confusion)
Barrel chest is often indicative of...
late stage Emphysema
Adult Scoliosis is defined as
lateral curvature that is >10 degrees by the Cobb angle in a skeletally mature pt.
most common reason for pulmonary hypertension
left heart disease ( heart failure or valvular dysfunction)
molluscum contagiosum lesion characteristic
lesions, also known as Mollusca, are small, raised, and usually white, pink, or flesh-colored w/ a dimple or pit in the center (called umbilical center)
Acute cough duration
less than 3 weeks
hcg lab value for (-) pregnancy
less than 5 mIU/mL
low dose COC contain how much estrogen
less than 50 mcg of ethinyl estradiol
at 20 wks gestation, fundus should be palpable at what leverl?
level of the umbilicus
antiepileptics regarded as safe during pregnancy
levitiracetam or lamotrigine monotherapy (most abundant and consistent data for low structural and neurodevelopmental teratogenic risk during pregnancy)
constipation first line tx
life style modifications - increase fibers and fluid and whole grains
Posterior sternoclavicular joint dislocation s/s
life threatening emergency -anterior chest and shoulder pain that is worsened by arm movement -dyspnea -dysphagia -upper extremity paresthesia -if posterior displacement of the medial clavicle or cllavicular fracture injures the recurrent laryngeal nerve, hoarseness may also be present -displacement may be diffuclt to appreciate
food poison pathogen in milk
listeria in raw milk
For patients with an animal bite injury in the absence of clinical evidence for infection, management involves...
local wound care foreign body removal (if present) administration of abx prophylaxis tetanus prophylaxis rabies prophylaxis
most potent type of diuretic is
loop diuretics *more potent than TZD but w/ shorter duration of action (BID)
good source of Ca+ include:
low fat dairy product (yogurt), dark leafy vegetables, canned salmon or sardines w/ bones, soy products, Calcium fortified cereals and orange juice
rubella: how bad is the fever?
low fever
Diphtheria clinical manifestation
low grade fever grayish "leathery" adherent nasopharynx oral pharynx or trachea
Pheochromocytoma workup
low index of suspicion: - 24 hr urinary fractionated catecholamine and metanephrine high index of suspicion: - plasma fractionated metanephrines *Biochemical confirmation should be followed by radiological evaluation to locate the tumor, not the other way around. CT/MRI of abdomen and pelvis is usually performed first
atopic dermatitis on face tx
low potency TOP CS (such as group/class 6) - desonide 0.05% up to 3 weeks OR TOP calcineurin inhibitor (tacrolimus 0.1% or 0.03% or pimecrolimus 1%)
Anorexia nervosa hospitalization indications
low wt, generally < 70% of the ideal wt or BMI physiological decompensation (severe electrolyt imbalance, cardiac dysrhythmias, altered mental status, other signs of severe malnutrition) acute medical complications of malnutritions (syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia) temp < 35 C pulse < 30 or <40 in presence of hypotension orthostatic pulse change > 20 bpm or decrease in systolic pressure > 20
lung cancer screening: test to do
low-dose commputed tomography in age 55-80 who have a 30 pack year smoking hx and currently smoke (or quit within the past 15 years)
rubella fever: how high
low-grade < 101.5 F /38.5 C
Ulcerative Colitis: pain location
lower abdominal cramping, LLQ
acute glaucoma often occur in the evening because...
lower light levels cause mydriasis and folds of the peripheral iris block the narrow angle
Ivabradine purpose and clinical indication
lowers HR w/o lowering BP, unlike BB, which lower both HR and BP used for pts who have chronic HF, not new onset, who are at class II -IV and EF less than 35%
Herpangina dx
made clinically, based upon the typical appearance and location of the oral enanthem (fewer than 10 hyperemic yellow/greyish-white papulovesicles on the anterior pillars of the fauces, soft palate, tonsils, and uvula) and associated high fever. Confirmation of a specific viral etiology is seldom necessary in children with uncomplicated HFMD or herpangina, but may be warranted if the diagnosis is uncertain (eg, isolated exanthem) and would affect management (eg, atypical HFMD versus eczema herpeticum) and in children with complications
mental health supplements
magnesium, folate, calcium deficiency found in sample of people w/ depression, anxiety, and both Good evidence on: - Chamomile - Passionflower - Kava Promising evidence on : - Magnesium - L-lysine - L-arginine
Chlamydia typical presentation
majority are asymptomatic when symptomatic: - in women: yellowish white foul mucopurulent endocervical discharge, scant clear watery urethra discharge, vaginal bleeding, vulvar & vaginal discomofort, pruritis (including bleeding after intercourse, dysuria), can become infertile - in men: scant white , cloudy, but mostly watery penile discharge, pruritus, dysuria, ulcerated papules and swollen inguinal lymph nodes if LGV, (only 2-4% of men report any symptoms)
Thiazide diuretic vs diabetics
majority suggest that these drugs tend to raise blood glucose can increase the risk for dx diabetes, especially more if taken with a beta blocker - there is evidence that when hypokalemia (low blood potassium) in these people is corrected, blood glucose control improves.
cluster headache epidemiology
male to female: 4.3:1 middle aged men most often affected
Ferritin normal range
male: 12-300 ng/ml female: 12-150 ng/ml
A positive Prehn sign def
manual elevation of the scrotum relieves pain
afp test is used for
may indicate a variety of conditions, such as neural tube defects and multiple gestationm Down syndrome, twins or multiple births (because more than one baby is producing AFP)
NIHSS stroke scale is used to..
measure the severity of acute stroke
Sulfonylurea vs Meglitinide
meglitinide: more rapid-acting w/ shorter duration
USPSTF Aortic Abdominal Aneurysm AAA screening
men at age 65- 75 yrs who have smoked - 1 time screening w/ US in men ages 65- 75 yrs who have smoked (over 100 lifetime cigarettes); individualize for men who never smoked
Positive McMurray's sign is pathognomonic for
meniscal tear
Ferrous Sulfate SE
metallic taste, nausea, flatulence, constipation, diarrhea, epigastric distress, and/or vomiting, itching, black/green or tarry stools that stain clothing
Alpha glucosidase inhibitor DI
metformin (additive GI SE) oral iron
Hashimoto most common population
middle age to older women
depression tx choice in pregnancy
mild/moderate: psychotherapy severe: psychotherapy + pharm, use Prozac or Zoloft, (Category C: SSRI, venlafaxine, trazodone, nefazodone, mirtazapine, bupropion, amitriptyline, desipramine, Category D: imipramine, nortriptyline)
Do not take Iron w/ what drink...
milk (interferes w/ absorption of Iron) *give w/ water or juice (orange juice pref) in between meals
tetracycline- avoid what
milk and antacids
Magnesium Hydroxide aka
milk of magnesia
mineral oil vs constipation
mineral oil is no longer recommended; deemed unsafe for oral congestion
According to the GOLD COPD guidelines, the goal of inhaled corticosteroid use in stage III COPD is to...
minimize the risk of repeated exacerbation
major disadvantage of low dose COC
more breakthru bleeding
Myelodysplastic Syndrome def
morphologic abnormalities in 2 or more hematopoietic cell lines, characterized by cytopenias, usually hypercellular marrow, and morphologic and cytogenetic abnormalities
Rotator Cuff Tear classic symptom
most cases have no symptoms at all (Several scientific studies have shown that up to 2/3 of the population at age 70 have rotator cuff tears; many of these people had no symptoms.) pain when lying on the affected shoulder *In young active people, full thickness rotator cuff tears are fairly uncommon. When they do occur, they are usually the result of a high-energy injury to the rotator cuff that is associated with throwing or overhead sporting activities.
Pediatric Constipation prognosis
most children w/ functional constipation require prolonged tx and have frequent relapses only 60% of children w/ constipation achieve tx after 1 year of therapy
Nexplanon side effects
most common - spotting in first 6-12 mths Sometimes - long term spotting - longer or heavier menstruation (but for most people, the implant makes their periods way lighter; some people even stop getting a period at all) Not common: - headaches - breast pain - nausea - wt gain - ovarian cysts - infx where the implant was inserted
TOP capsaicin common SE
most common SE: local burning sensation (typically mild to moderate and improves w/ continued application)
St. John's wort may interact w/ what drugs?
most drugs, including statins, warfarin, and antidepressants
Gonorrhea typical presentation in female
most genital infx are asymptomatic cervix is the most commonly infected mucosal site; when symptomatic, - gonococcal cervical infx w/ the typical findings of cervicitis, including vaginal pruritus & copious mucopurulent cervical discharge. - PID and infertility are complication of untreated urogenital gonococcal infx
Adult Constipation def according to patient
most older persons perceive constipation as straining during defecation and difficulty in evac
Concussion Management <concussion tx, concussion nonpharm, concussion pharm>
most pts recover in 48-72 hrs, even w/ detailed neuropsychological testing, and are headache free within 2-4 wks of injury Cognitive and physical rest is the mainstay of management of pts with concussion Ongoing neuropsychological testing is a helpful tool during management The main criteria for an athlete's return to play after a concussion include the following: -complete clearing of all symptoms - complete reutrn of all memory and concentration - no symptoms after provocative testing: provocative testing includes jogging, sprinting, sit-ups, or pushups (ie, exercise that raises the athlete's BP and HR) Medications: - No medical therapy is usually prescribed for pts. - Pain control is usually achieved w/ OTC - Overuse of analgesics following injury may exacerbate concussion related headaches or make them chronic Admit to hospital for any decreased LOC, seizures, focal deficits, vomiting, and positive head CT findings Concussion criteria tool - CDC Acute Concussion Evaluation (ACE) tool
Cushing Syndrome s/s
most suggestive signs 1. proximal muscle weakness 2. facial plethora 3. wasting of extremities w/ increased fat in the abdomen and face (increased fat d/t increased appetite / "stressed eating") 4. wide purplish striae 5. bruising w/ no obvious trauma 6. supraclavicular fat pads s/s list: 1. Moon face (due to fat deposits on the sides of the face) 2. Buffalo hump 3. Thin arms and legs 4. Emotional Instability 5. Fatigue 6. Poor Wound Healing 7. Ecchymosis 8. Purple striae on abdomen 10. fracture (osteoporosis d/t cortisol removing Ca+ from bones) 11. hyperglycemia (can progress to diabetes, HTN, amenorrhea, poor wound healing)
CK-BB is found where?
mostly in your brain. It's also found in smooth muscles such as the intestine or uterus. it's not normally detected in your blood
molluscum contagiosum: tx
mostly self limited curretage, podophyllin, cantharidin, cryosurgery, genital area should be tx'ed after weighing potential for sexual transmission
Crohn's affect which part of GI?
mostly terminal ileum and colon
meclizine use
motion sickness / meniere's diseaes / vertigo
DPP-4 inhibitor dosing schedule
must be taken immediately before meals
Asymptomatic Bacteriuria Tx target population
must be tx'ed for... - Genitourinary procedure who have obstructive uropathy, stones, hx of recurrent symptomatic infx
celiac disease vs anemia: relationship
must check for anemia during PE for celiac pt because Celiac disease can cause damage to the small intestine where iron, folate, and vitamin B12 are absorbed. The most common sign of celiac disease in adults is iron-deficiency anemia that is unresponsive to iron therapy.
Diphtheria dx
must have + culture skin or resp secretions
Multiple Sclerosis def
myelin sheath destruction. disruptions in nerve impulse conduction
live attenuated flu vaccine: route of administration
nasal spray
rotavirus infx: most prominent symptom
nasty diarrhea (severe acute gastroenteritis) and vomiting
Melatonin - def
natural hormone secreted by the pineal gland in response to signals from the suprachismatic nucleus from the hypothalamus. It controls circadian rhythm and aids in initiating and maintaining a regular sleep cycle. Studies have shown that the concentration of melatonin is low during the day, increases at sunset, peaks between 11pm and 3 am, and falls sharply at dawn. It is indicated for age-related insomnia, and its AE profile is safe, even at relatively high doses.
Gout Definitive Diagnostic
needle aspiration of the acutely inflamed joint or suspected tophus (can visualize uric acid on gram stain)
Cortisporin is composed of
neomycin polymyxin B sulfates hydrocortisone otic solution
Koebner phenomenon
new psoriatic plaques form over areas of skin trauma
Dihydropyridine CCB list
nifedipine amlodipine others
Is constipation a normal part of agin?
no
benefits of tricyclic over monophasic COC
no actual substantial benefits noted
pregnancy and lactation vs antiemetic
no antiemetic drugs should be used during pregnancy unless prescribed by the obstetrician phenergan and reglan are commonly used during pregnancy
baby hiccup: concerns
no concerns (doesn't affect baby's breathing)
Polymyalgia Rheumatica dx:
no pathognomonic test or established diagnostic criteria following criteria (this is not a DIAGNOSTIC criteria): - age 50 or older at disease onset - proximally and bilaterally distribution of aching/stiffness lasting 30 mins or more for at least 2 wks - stiffness involves at least 2 of the following 3 areas: neck or torso, shoulders or proximal regions of the arms, and hips or proximal aspects of the thighs. - elevated acute phase reactants, especially the CRP - *Rapid resolution of symptoms w/ low-dose glucocorticoids (symptoms generally 50-70 % better within 3 days in pts w/ PMR started on prednisone at dose of 10-20 mg/day, and almost all patients responded completely within 3 weeks) *initial eval of pt w/ suspected PMR includes a complete hx and physical, as well as selected lab testing -CMP including BUN, CRE, Ca+, Phosphate -LFT -rheumatoid factor -urinalysis -thyroid stimulating hormone
Diverticulosis management
no reason to treat until inflammation occurs; should avoid laxatives *high fiber diet* after acute phase or flare up is over - clear liquid diet (advance slowly over 48-72 hrs) 7-10 day broad spectrum abx (if diverticulitis) - Cipro and Flagyl - Bactrim and Flagyl - Moxifloxacin - Augmentin Analgesia - 1st line: tylenol - 2nd line: tramadol
FDA Category A
no risk to human fetus
meningococcal vaccine contraindication
no specific contraindication to neither vaccines
Hep A contraindication
no specific contraindications
HiB: Absolute Contraindications
no specific contraindications
HPV contraindications
no specific contraindications -not recommended in pregnant females
Roseola tx
no tx no vaccine
roseola vaccine
no vaccine available
Toxoplasmosis prevention
no vaccine available pt edu: - cook meat thoroughly - don't change the cat litter box yourself
should intact burn blister be unroofed?
no, keep it intact d/t infx risk
does premature contraction mean premie?
no, premature *birth* means subsequent premature births
can PPSV23 be given to all children?
no, single dose can be given to children older than 2 y/o w/ *special medical conditions* - chronic heart or lung disease - diabetes mellitus - CSF leaks - cochlear implants two doses can be given if child has following conditions (2nd dose at least 5 yrs later) - SCD - congenital or acquired asplenia - splenic dysfunction - HIV infx - CKD - nephrotic syndrome - congenital syndrome - congenital immunodeficiency - immunosuppressive drug tx - radiation therapy
Obstructive Sleep Apnea diagnosis
nocturnal polysomnography
roseola: rash pruritic?
non-pruritic skin rash
Intussusception tx
nonoperative reduction using hydrostatic or pneumatic pressure by enema is the tx of choice if client is clinically stable and has no evidence of bowel perforation or shock. Reduction of intussusception is most commonly guided by fluoroscopy or US. Surgical tx is available for patients with suspected perforation or appearing acutely ill.
Obstructive Sleep Apnea management
nonpharm 1. wt loss (healthy diet, exercise) 2. avoid ETOH (depresses central 3. sleep position (sleeping in supine position worsens OSA; these pts are less obese and younger than non-positional; sleeping in non-supine position may correct or improve OSA and is encourage but is not generally relied upon as the sole therapy; sleeping in a non-supine position should not be used as the primary therapy unless normalization of the AHI (normal : < 5) when sleeping in a non-supine position has been confirmed by sleep test) Severe OSA (AHI >= 30 events/hr) - initial therapy: CPAPs Mild/moderate OSA - initial therapy: CPAPquiz
Janeway lesions
nontender hemorrhagic lesions - fingers, toes, nose, earlobes - a/w endocarditis
Vitamin B12 Normal Range
normal > 400 pg/mL B12 deficiency possible 150-400 pg/mL B12 deficiency likely < 150 pg/mL
A urinalysis dipstick test indicated that urobilinogen was absent. Which condition does this support?
normal condition
Klebsiella
normal flora of
FEV1 -normal value -mild restriction -moderate restriction -severe reduction
normal: 80-120% of predicted mild: 70-80% moderate: 50-70% severe: <50%
LH to FSH ratio range
normal: near 1:1 PCOS: 2:1 or even 3:1 (LH often at 10-20 while FSH often at 4-8; pt who fit the PCOS syndrome in other ways may have normal serum FSH and LH lvls and normal FSH to LH ratio)
Acute Leukemia Patho
normally percentage of blast cells in bone marrow is 1-2%. W/ acute Leukemia it goes above 20%, which crowds out other cells.
HgbA1C vs pregnancy
not really accurate or helpful during pregnancy
cimetidine vs pediatric
not recommended for children < 16 y/o
pregnant mom: when to do US
not until 18th wk gestation unless you are uncertain of dating (ACOG)
Bacterial meningitis common s/s
nuchal rigidty high fevers photophobia headaches altered mental status vomiting purple rash in 50% of bacterial cases by meningia (indicates davanced stages of the infx)
S3 is heard when
occurs in many children and young adults under age 40 (benign) adult: volume overload (in older adults w/ heart disease, this often signifies myocardial failure)
Chronic hypertension with superimposed preeclampsia DEF
occurs in women with chronic hypertension before pregnancy who develop worsening high blood pressure and protein in the urine or other blood pressure related complications during pregnancy.
Addison's disease
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone
pleuritic pain characteristic
often asymptomatic initially often sharp, unilateral, and localized to affected area; dullness to percussion and decreased BS over effusion may also have pain in lower chest and ipsilateral shoulder or referred to abdomen exacerbated by deep inspiration, cough, upper-body movement
Carotid Artery Stenosis s/s
often asymptomatic until they show up with a stroke If focal neurological symptoms of acute onset, may display... - sensory alterations - monoparesis or hemiparesis - paresthesia - visual changes: blurred, blindness in one eye - visual field loss - dimming of vision - speech disturbance (expressive or receptive aphasia, change i n speech pattern or vocal quality)
telogen effluvium appearance
often notice clumps of hair coming out in the shower or in hairbrush most noticeable in temporal region but uniform hair thinning (presence of erythema, scaling, inflammation, altered or uneven hair distrbution or changes in shaft caliber, length, shape or fragility may suggest other dx's_
what to do if INR of less than 5 w/ no significant bleeding risk
omit one dose and/or reduce maintenance dose slightly ; recheck INR
when to take glucocorticoid during the day
once a day or alternating day dosing before 9 am
which abx interferes w/ contraception
only Rifampin
Narcolepsy s/s
only a minority will experience 5 key symptoms 1. daily sleepiness 2. cataplexy 3. inability to move at start or end of sleep 4. vivid hallucinations around edges of sleep 5. fragmented sleep
vancomycin targets what
only gram positive bacterias
Shoulder Impingement s/s
onset of pain may be acute or chronic, accompanied by a grinding sensation during shoulder movement pain, weakness, decreased range of motion in the shoulder, pain is often exacerbated by shoulder movement, especially when lifting the arm over the head typically, pain is not related to temperatures, worsens in the evening, and improves w/ lidocaine injection
clonazepam - onset - duration of action
onset: 1 hr duration: 6-12 hrs
when would Acamprosate be considered over Naltrexone
opioid use (Naltrexone cannot be given to pts needing to contineu opioid) acute hepatitis, liver enzymes >=3-5 times normal or liver failure (Naltrexone a/w hepatotoxicity, particularly at higher doses)
afib recommended anticoagulant
oral direct thrombin inhiibtor or factor Xa inhibitor rather than warfarin
candidiasis anal from inside is tx'ed w/
oral nystatin
High purine foods
organ meats, seafood and fish like anchovies, herring, mackerel, sardines, beans, meat, asparagus, cauliflower, mushrooms, spinach, alcohol
Atypical antipsychotic common SE
orthostatic hypotension sedation newer atypical antipsychotics are felt by many to have a lower risk of TD. *Second gen ("atypical") antipsychotic have increased incidence of metabolic abnormalities (wt gain, diabetes, hyperlipidemia)
Peptobismol should not be taken with what other meds
other meds w/ salicylate: high dose ASA, anticoagulant
Medicare B covers
outpatient insurane and prescription medical equipment
Homan's sign
pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis / DVT
HFMD tx
pain med adequate hydration no vaccine available
Clavicle fracture pain
pain upon palpation and typically deformity of the clavicle
Interstitial Cystitis common signs
pain w/ bladder filling urinary urgency urinary frequency
osler's nodes
painful nodules on finger and toe pads....seen in endocarditis caused by strep viridans
Hidradenitis suppurativa s/s
painful, tender firm nodules that may open and drain over 10-30 days areas: anxillary, inguinal, areolar, pubic area, gluteal folds, top of anterior thighs, perianal region surrounding cellulitis may occur
visual inspection of pt w/ neurofibromatosis may note
painless, mobile lumps under skin (more common in type 1) cafe-au-lait spots (more common in type 1) lisch nodules on iris that always appear by age 6 but has no sight problems
afib symptoms
palpitation tachycardia fatigue weakness dizziness lightheadedness reduced exercise capacity increased urination mild dyspnea more severe s/s: - dyspnea at rest, angina, presyncope or infrequently
Mitral regurgitation heart sound
pansystolic murmur that radiates to the axilla, and is loud and high pitched when auscultated
clinical pearl: high index PE finding indicating rabies
paresthesia around the bite/injury
Which SSRI should not be used in pregnancy?
paroxetine
Alopecia Areata appearance
patchy hair loss, 2-5 cm in diameter w/ exclamation point hairs that break before reach skin surface (autoimmune) *fingernails may show fine pittings
melasma pathophysiology
pathogenesis of melasma has not yet been fully elucidated - acquired hypermelanotic condition presenting with light-to-dark brown-colored irregular macules on sun-exposed areas of the skin, especially that of the face
Iron Deficiency, IV Iron indication
patients who cannot tolerate the side effects of oral replacement (e.g., pregnant women or patients with GI disorders) patients who do not sufficiently respond to oral replacement. Other indications for IV iron: bariatric surgery status, heavy uterine bleeding, malabsorption, inflammatory bowel disease, ongoing/severe losses
PTU contraindication
peds - should not be used in peds unless the pt is allergic to or intolerant of methimazole and no other tx options are available
Mycoplasma pneumoniae are resistant to
penicillin
parietal cell antibody is present in...
pernicious anemia
Koebner response
picking and scratching exacerbate the lesion and proliferate it further
Low and High Dose Dexamethasone test results
pituitary tumor - low dose dexamethasone: high cortisol, high ACTH - high dose dexamethasone: low cortisol, low ACTH (dexamethasone inhibits pituitary tumor) adrenal tumor - low dose: low ACTH, high cortisol - high dose: low ACTH, high cortisol Ectopic source - low dose: high ACTH, high cortisol (ACTH will continue to be high b/c tumor doesn't respond to dexamethasone) - high dose: high ACTH, high cortisol (ACTH will still continue to be high b/c tumor doesn't respond to dexamethasone)
Preeclampsia complications
placental abruption, coagulopathy, renal failure, uteroplacental insufficiency, eclampsia
ANA test
plasma is tested for antibodies that are present in patients with SLE, rheumatoid arthritis, and other autoimmune disorder
sickle cell vs malaria
plasma vivax uses specific receptor on RBC called Duffy Antigen; those w/ SCD lack these receptors on RBC surface
crackles in lung field are pathognonic for...
pneumonia
Pneumonia vs acute bronchitis s/s
pneumonia usually presents w/ systemic signs such as fever
Sturge Weber
port-wine stain over trigeminal nerve, causing seizures and other symptomatology
Rubella which lymph node involved?
postauricular, posterior cervical
Diuretic lab work
potassium, magnesium
Cytotec contraindication
pregnancy (stimulates uterine smooth muscle, can induce labor)
Misoprostol Contraindication:
pregnant women (stimulates uterine smooth muscle and can induce labor)
Pregnancy vs travel to Zika areas
pregnant women SHOULD NOT travel to any areas w/ risk of Zika. *If must travel to area w/ Zika risk, take strict precautions to prevent mosquito bites and avoid sexual transmission.
Otitis Media with Effusion def <OME>
presence of middle ear fluid without acute signs of infection
intraocular hypertension def
pressure > 21 mmHg
Mononucleosis epidemiology
prevalent among teens in US; ~90% of adults in the US have antibodies against EBV -EBV acquired during childhood years is often subclinical (less than 10% of children develop clinical infx depsite high rate of exposure. - development of symptomatic infection begins to rise in adolescent through adult years. - peak incidence of infx occurs in the 15- 24- year age range. - IM is rare in adults - 30x more likely in whites than blacks in US (may reflect earlier exposures to EBV among the latter group and higher frequency of asymptomatic infx when acquired by young children)
Bisphosphonate purpose
prevents bone loss in osteoporosis
Alopecia Areata ddx
primarily includes: other causes of nondiffuse hair loss - Androgenetic Alopecia - Scarring alopecia - Trichotillomania - Secondary syphilis - Tinea Capitis
Baclofen use
primarily used for spasticity in spina cord injury pts or those w/ multipe scerosis. There are better options for neck and back muscle pain, so this is not a first choice.
Aphthous stomatitis vs Herpes simplex virus
primary herpetic gingivostomatitis may present w/ extensive oral ulcerations. Recurrent herpes simplex virus often involves the cutaneous lip as well. It is unusual for these lesions to develop within the oral cavity. When this does occur, it is typically on the masticatory mucosa of the gingivae or hard palate.
primary vs secondary raynaud's disease
primary: idiopathic and not a/w other disease, affects fingers + toes symmetrically, severity stays constant secondary: a/w other diseases (e.g. SLE, scleroderma) *secondary Raynaud Disease is also called Raynaud Syndrome
Herpes s/s
prodrome 1-2 days before s/s (tingling, burning) -first infx may have vflu-like symptoms, such as fever, chills, muscle aches, fatigue, and nausea. HSV 1 s/s: - lesions on gums palate tongue, lip, facial area, stomatitis - systemic sxs such as fever, malaise, headache (recurrent Herpes is rarely associated with systemic symptoms) - lymphadenopathy - pharyngitis in older children and adults -*reactivation: is often asymptomatic, but some s/s can include handful of blisters at the vermillion border on one side of the face HSV 2 s/s: - pustules / ulcers on labia majora & minora, mons pubis, vagnial mucosa, cervix (and shaft of penis on men) - *reactivation is often asymptomatic but s/s include few blisters that resolve rapidly around in a week
PPI MOA:
prodrug that binds and irreversible block H+/K+ ATPase pump in parietal cells continuously for 1- 2 days *requires parietal cell conversion to active metabolites that bind to proton pump
Trichomoniasis discharge characteristic
profuse frothy greenish discharge bad smell
Am I protected if I have missed 2 or more pills? pt instruction?
protection may be affected if msised 2 or more pills anywhere in the pack or started new pack 2 or more days late -take the last pill ASAP, even if it means taking 2 pills in 1 day - leave any earlier missed pills -carry on taking the pack as normal - use extra contraception for the next 7 days
PCR use
provides the specific segment that will be used in gene cloning - Used to amplify DNA from wooly mammoth, blood, fingerprints, HIV cells, embryonic cells for prenatal diagnosis
Proper breastfeeding position
pt lying comfortable on your side or sitting in a chair Cradle the infant next to the breast w/ their head propped up by the mom's arm place baby's stomach flat against mom's upper abdomen, in the same plane
Herpes Asymptomatic Viral Shedding - def
pt shed viral pathogens and is contagious even when asymptomatic - 70% of transmission cases - 89-90% of seropositive pt does this
Carvedilol contraindication
pt w/ hypotension or AV blocks
Rheumatoid Arthritis vs Osteoporosis
pts w/ RA are at inc risk of osteoporosis, osteopenia, bone fractures -mgmt - adequate physical activity, optimize calcium and vit d; minimize steroid therapy; consider bisphosphonate tx
Endocarditis prophylaxis recommended for
pts w/ high risk conditions undergoing high risk procedures high risk condition: - previous hx bacterial endocarditis - prosthetic valves - certain types of congenital heart disease - Valve regurgitation due to a structurally abnormal valve in a transplanted heart high risk procedures - dental procedures that traumatize oral mucosa, gingiva, or periapical area of the teeth 0 invasive procedures on the respiratory tract (especially if tissue is infected)
when would you provide cardiac referral?
pts w/ stable NYHA class II to III HF, refer to cardiac rehab programm - not enough data at present to recommend cardiac rehab for pts w/ advanced HF
osteoporosis vs steroid
pts who take 7.5 mg or more of prednisone per day for more than 1 mth have been identified as being at higher risk
afib dx
pulse rate confirm w/ EKG -if still suspicious, use holter monitor or event monitor -do labs
Gonorrhea discharge character
purulent discharge from urethra
venous hum how to differentiate it from heart murmur
put a finger on the jugular vein; it will abolish the venous hum but not the heart murmur
UTI w/ fever greater than 100.2, N/V, systemic symptoms: probable dx
pyelonephritis
Toxoplasmosis tx
pyrimethamine + sulfadiazine
How often do you change insulin pump infusion set
q 24- 48 hrs for metal needle depending on the brand q 48-72 hrs for soft cannula depending on the brand
OA: f/u frequency
q 3 mths (if s/s in process of being controlled) q 12 mths (if well controlled)
osteoarthritis vs radiograph
radiographic exam may be used to support a OA dx but IT IS NOT A ROUTINE TEST to consider. Pt w/ robust OA dx on clinical grounds MAY HAVE NORMAL RADIOGRAPH FINDINGS and vice versa X-rays are usually normal early in disease process. MRI may particularly demonstrate chondral degeneration and associated meniscal tears. 5-10% weight loss is associated with slowing of arthritic changes and decreased chondral loss on follow-up studies
most common allergic reaction to fluoroquinolone is
rash (most common allergic reaction, but rare)
Morbilliform
rash that looks like measles. maculopapular lesions that are red and usually 2-10 mm in diameter and become confluent on the face and body.
severity of altitude sickness is affected by
rate of descent/ascent and physical exertion (exercising, etc) not affected by person's physical fitness
The ultimate tx goal for T1DM <diabetes>
re-create normal (non-diabetic) or NEARLY normal glucose lvl w/o causing hypoglycemia
rhinitis medicamentosa
rebound nasal congestion commonly associated with overuse of OTC nasal decongestants
First Generation Antipsychotics are effective at...
reducing positive symptoms, but not effective on negative symptoms
Acute Cholecystitis management
refer immediately for admssion - analgesia - IV rehydration - abx theraepy
Aplastic Anemia stable pt management
refer the stable patient to a hematologist
OA: who and when to refer
refer to Orthopedic surgeon when recalcitrant s/s or functional impairment warrant consideration of joint replacement surgery of the hip or knee
Diabetic foot ulcer treatment
refer to foot care specialist (podiatrist)
Ulcerative Colitis: management
refer to gaastroenterologist topical mesalamine (rectal)- 1st line tx for inducing remission
Pediatric Constipation referral
refer to pediatric gastroenterologist when red flag noted or when unresponsive to adequate therapy
Crohn's: management
referral to gastroenterologist corticosteroid
cryptorchidism management
referral to urology -Congenital palpable or nonpalpable undescended testes (unilateral or bilateral); referral between 4 and 12 mths of age is recommended -newborn infants with bilaterally nonpalpable testes, unilaterally nonpalpable testis w/ hypospadias, or suspected disorder of sex development (including congenital adrenal hyperplasia) should be immediately referred to a multidisciplinary team for eval and initial management of possible disorder of sex development. *Most testes that are undescended at birth complete their descent spontaneously within the first 3 to 4 mths of life.
1st step to txing acute diarrhea is..
rehydration, preferably PO
Copper IUD MOA
release copper ions, which are toxic to sperm. They also cause the uterus and fallopian tubes to produce a fluid that contains white blood cells, copper ions, enzymes, and prostaglandins, which is also toxic to sperm.
how does Terazosin help BPH?
relieves the symptoms of BPH by relaxing the muscles of the bladder and prostate. *also is antihypertensive
Molluscum contagiosum follow up
repeat exam recommended 2-4 wks after tx. retreat often is necessary. consider combo therapy in pts whose lesions respond poorly.
huntington disease cause
repeated sequences of DNA cause abnormal protein that lead to abnormal movement and cognitive problems autosomal dominant (one copy of affected gene is enough to cause the disease)
PMS dx
requires 1-4 symptoms that may be physical, behavioral, or affective
mycoplasma target abx
resistant to cell wall abx targeted by macrolides, tetracyclines, fluoroquinolone if resistant to fluoro, use doxycycline and minocycline
hordeolum tx
resolve spontaneously over several days and do not require specific intervention managed with warm compresses, which are placed on the face for about 15 minutes four times per day, in order to facilitate drainage If, despite management with warm compresses, the lesion does not reduce in size within one to two weeks, the patient should be referred to an ophthalmologist for incision and drainage. There is little evidence that treatment with topical antibiotics and/or glucocorticoids promotes healing.
How to test physically for hip osteoarthritis
restriction to internal rotation of hip
Rheumatoid factor is used to test for...
rheumatoid arthritis
Pregnancy vs riding bike
riding bicycles, motorcycles, or animals present risk of trauma to the abdomen and are not recommended.
foreign body aspiration: which bronchus is typically obstructed?
right maintem (wider and is more vertical)
Hand foot mouth disease ddx
roseola herpangina varicella insect bites aphthous stomatitis stevens johnsoon syndrome contact dermatitis eczema herpeticum id reaction
TZD list
rosiglitazone (Avandia) Pioglitazone (Actos)
Rotavirus vaccine schedule
rotarix: 2, 4 mth rotateq: 2, 4, 6 mth maximum age for the final dose: 8 mths 0 days do not start series on or after age 15 wks 0 days
neutrophil function
roughly half of WBC -first to respond to invader/bacteria/virus -phagocytize pathogens or debris *they live only for for 8 hours when produced by bone marrow *around 100 billion of these are produced every day
Hepatitis A schedule
routine: 2 doses, 1st dose at 12-23 mths minimum 6 mths for next dose for both routine and catch-up Anyone 2 years of age or older may receive Hep A vaccine if desire international travel: - Unvaccinated age 12 months and older: Administer dose 1 as soon as travel is considered. - Infants age 6-11 months: 1 dose before departure; revaccinate with 2 doses, separated by at least 6 months, between 12 and 23 months of age
TIA clinical presentation <stroke, CVA, transient ischemic attack, TIA>
s/s generally last less than an hour but may have permanent sequelae Acute onset of focal neurologic deficit - limb weakness or numbness - facial weakness - speech difficulty to aphasia - visual loss/blurring - ataxia
prescription med for motion/sea sickness:
scopolamine
scopolamine vs meclizine
scopolamine has proven to be more effective than meclizine
CCB contraindications
second or third degree heart block bradycardia congestive heart failure
pt w/ neurofibromatosis are at increased risk of
seizures learning difficulties malignant peripheral nerve tumors large neurofibromas can press on nearby organs
Weber test lateralization to good ear result
sensorineural loss presbycusis meniere disease
Antacid: solution to prevent DI
seperate antacids and drug by about 2 hrs
infant w/ high fever may likely be...
sepsis
Janeway lesion cause
septic emboli of infective endocarditis cause small painless flat erythematous lesion
Iron Deficiency Anemia vs Hair loss
severe iron deficiency anemia leads oxygen to be redirected from cells that keep hair holding on to hair to vital organs
subcutaneous immunotherapy contraindication
severe or very labile asthma (relative contraindication, can lead to severe bronchospasm)
Rotator Cuff Tendonitis signs
shoulder weakness and difficulty lifting the arm over the head pain and swelling in the front of the shoulder clicking sound when the arm is raised general stiffness
Aldosterone Antagonist clinical purpose in HF
shown to reduce HF-related morbidity and mortality, typically in pts who have class 2 to 4 HF but come w/ SE such as hyperkalemia and gynecomastia, or breast tenderness, both in men and women. -this is diuretic but that's not the main reason you are using them.
CK MM is found in
skeletal muscle
Stasis dermatitis - def
skin thickening and discoloration occurs in the lower leg when varicose veins slow the return of blood and the accumulation of fluid interferes with the nourishment of the skin
dermatophyte only grows on ______, ________, and ________ because...
skin, hair, and nail because dermatophytes are fungi that require keratin for growth
Skyla vs Mirena
skyla - lower dose progesterone releasing IUD - smaller in size than Mirena so less pauinful Mirena - more progesterone released, so better control w/ bleeding
Parkinson's disease tremor characteristic
slow coarse resting tremor w/ 2-5 oscillations/second when hand is motionless
corticosteroid onset
slow onset of action (hours)
Lomotil moa
slows peristalsis
Hegar's sign
softening of the lower uterine segment feels like an hinge upon palpation as if there were two parts
splitting heart sounds of S1 or S2 is normal in...
some children, young adult, and pregnant clients
pregnant mom: when should GBS be tested?
sometime by and after 35th wk gestation
Ivabradine MOA
specifically inhibits the cardiac pacemakers
testicular torsion: very specific physical finding
spermatic cord shortens as it twists, so the testis may appear higher in the affected scrotum. This is a very specific finding and, when present, is strong evidence of testicular torsion
Threatened Abortion definition
spotting & cramping without cervical change (as opposed to "inevitable abortion" w/ cervical change)
GOLD COPD staging criteria
stage 1: mild obstruction - FEV1 > 80% of predicted value - some sputum - chronic cough stage 2: moderate obstruction - FEV1 between 50-80% of predicted value - SOB on exertion - chronic symptoms Stage 3: severe obstruction - FEV 1 between 30-50% of predicted valuee - dyspnea - reduced exercise tolerance - exacerbations affecting QOL Stage 4: very severe obstruction - FEV1 < 30% of predicted value OR moderate obstruction FEV1 less than 50% predicted value and chronic respiratory failure
clear cut impetigo is caused by
staph
if pus in ear, common pathogen is
staph (could be due to trauma and penetration)
secondary infx of Aphthous stomatatis
staph auerus
infection a/w cream filled bakery
staph aureus
Coumadin dosing
start 2-5 mg PO QD (maintenance dose 2 to 10 mg PO QD based on INR)
USPSTF breast cancer screening
start age 50 yrs - mammogram q 2 yrs (biennial) until 74 -stop at 75 or continue if high risk May start at 40-49; the decision should be an individual one (for women who place a higher value on the potential benefit than the potential harms) - mammogram q 2 yrs - number of false-positive results and unnecessary biopsies is larger Women deemed to be at high lifetime risk of breast cancer (eg, those who have BRCA or other susceptibility genes, or a history of chest radiation, or a calculated lifetime risk of developing breast cancer of greater than 20 percent), should undergo annual screening mammogram, annual breast magnetic resonance imaging (MRI), and clinical breast exam every 6 to 12 months beginning 10 years prior to the age at diagnosis of the youngest affected family member but not prior to age 30 for mammography and not prior to age 25 for MRI Breast self-exam (BSE): against teaching BSE (Grade D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer.
Hep A schedule
start at 1-2 years old (2 doses-6 months apart) *minimum age: 1 mth *Anyone 2 yrs or older may receive Hep A vaccine if desired. Minimum interval between doses: 6 mths
statin vs pregnancy
statin is teratogenic and should be used w/ caution in women of reproductive age and ALWAYS in conjunction w/ effective birth control
Vestibular neuritis tx:
steroid therapy during acute phase - Methyprednisolone daily for 22 days; begin w/ 100 mg then taper and decrease q 3 days - PT exercises for vestibular enhancement
buckle fracture: is it treated differently
still about same, with age in mind, still cast them
Narcolepsy tx
stimulants and SSRI -methyphenidate or modafinil; sodium oxybate for cataplexy
docusate sodium class
stool softener / surfactant laxative / emollient
Contact lens vs tap water
storing contact lens in tap water promotes bacterial growth
dirty looking impetigo is caused by
strep
most common cause of acute OM
strep
erysipelas most common pathogen
streptococcus
chickenpox secondary bacterial infx
streptococcus and staphylococcus a
Cataplexy triggers
strong emotions -laughing at a joke -winning a game -anger
Molluscum contagiosum: 1st line tx
strong evidence for the efficacy of any tx for molluscum contagiosum is lacking -in immunocompetent individuals, it is generally self-limited and heals spontaneously after 6-18 mths. Tx may not be required but it may help to reduce autoinoculation or transmission to close contacts and improve clinical appearance.
Mild Otitis Externa Tx:
suggest a non-abx topical prep (acidifying agent, glucocorticoid) -Hydrocortisone-Acetic Acid Otic (it combines the antibacterial and antifungal action of acetic acid with the anti-inflammatory functions of hydrocortisone.) *prefer not using a topical antibiotic because of the marginal additional benefit for mild disease.
high temp (above 101.5 degrees fahrenheit) of pt w/ appendicitis denotes
suggest that the appendix may have already burst.
Thiazide diuretic contraindication
sulfa allergy (sulfonamide antibiotics share a common structural element w/ many nonantibiotic drugs, including thiazide and loop diuretics, sulfonylurea, etc)
Migraine abortive tx
sumatriptan, IV dihydroergotamine (ergot) dopamine blockers for N/V (metoclopramide)
Still's murmur is louder in which position
supine
RSV tx
supportive care
Meniere Disease: acute management
supportive care - Rest w/ the eyes closed - Protect from falling Short-term medications: Physicians may prescribe short-term medications to be taken during an episode of vertigo to lessen the severity of an attack. Medications such as meclizine or diazepam may reduce the spinning sensation of vertigo and help control nausea and vomiting. Drugs such as promethazine may also control nausea and vomiting during an episode of vertigo.2,6
Herpes prophylaxis in pregnant mother
suppressive viral therapy starting near term (36th wk) to reduce the risk of asymptomatic shedding and the risk of an active outbreak at time of delivery *ALL WOMEN W/ HX of genital herpes should have a exam looking for lesions on admission. Any vulvar or vaginal lesions should lead to a recommendation for C-section to reduce the risk of vertical transmission.
craniosynostosis tx
surgical referral d/t increased ICP or cosmetic reasons *best cosmetic efx noted if surgery performed during first 6 mths of life
Obstructive Sleep Apnea workup
suspect OSA whenever pt presents w/ excessive daytime sleepiness, snoring, and choking or gasping during sleep Diagnostic testing for OSA should be performed on pts w/ excessive daytime sleepiness on most days AND the presence of at least TWO of the following clinical features of OSA: 1. habitual loud snoring 2. witnessed apnea or gasping or choking during sleep 3. diagnosed systemic HTN In the absence of above criteria, many experts also perform diagnostic testing in the following 1. EDS alone (excessive daytime sleepiness) 2. patients who have other clinical features of OSA (e.g. obesity fatigue upper airway abnormalities, snoring) AND conditions or complications a/w OSA (e.g. refractory HTN, afib, nocturnal angina or dysrhythmias, CHF, stroke, and TIA) 3. pts in whom OSA needs to be ruled in or out as an underlying cause or potential contributing factor to their symptoms (e.g. motor vehicle accident due to falling asleep)
Acute Bronchitis dx
suspect in: - acute onset but persistent cough (often lasting 1-3 wks) who do not have clinical findings suggestive of pneumonia (fever, tachypnea, rales, s/s parenchymal consolidation) and do not have COPD It can be a clinical dx. For most pts, the dx can be made based upon the hx and PE. CXR: primary reason is to exclulde pneumonia. in pts w/ acute bronchitis, CXR are either normal or findings are nonspecific, though subtle changes consistent w/ thickening of the bronchial walls in the lower lobes are occasionally reported. Chest radiographs are unlikely to change management for most pts w/ acute cough. Microbiologic testing largely unnecessary.
Hidradenitis suppurativa def
sweat gland infection in the axilla
ways to combat sexual dysfunction SE of antidepressant
switch patient to low dose wellbutrin Maca PO BID (there's insufficient evidence but early research suggests that it improves sexual dysfunction in men and women) *We currently have no information for MACA Interactions.
Psoriasis typical plaque locations
symmetrically distributed most commonly on the scalp, extensor surfaces of extremities, and trunk
at 12 weeks gestation, the fundus of the uterus should be located approximately at...
symphysis pubis
Amytrophic Lateral Sclerosis management
symptomatic, no cure riluzole FDA approved for tx surgery supportive care
Rocky Mountain Spotted Fever s/s
symptoms begin occuring a wk or 2 after the initial tick bite -fever -n/v -headache -myalgias -characteristic small flat pink petechiael rash that begins on the extremities and move inward toward the trunk as the rash progresses
functional somatic syndromes
symptoms, suffering, & disability with indeterminate cause
palpitation: what other symptoms would be considered red flags?
syncope or presyncope -requires full cardiac workup
Otitis Externa w/ Deeper tissue infection Tx:
systemic + topical Abx -Ciprofloxacin, ofloxacin
Herpes initial s/s
systemic s/s (fever, malaise, headache, myalgia, lymphadenopathy) are usually present w/ the 1st infx. recurrent infx may only present w/ a prodrome of genital tingling or burning followed by geital lesions.
If abnormal ASQ-3 is noted, what would you do as a PCP?
take immediate action - discuss concerns w/ parents - complete a more focused assessment - objective vision/hearing eval, metabolic testing, measurement of lead level - for children older than 3 y/o: a local public school should be contacted for evaluation services. - for more extensive developmental testing, referral to a developmental pediatrician, child psychiatrist, or pediatric neurologist should be considered - for concerns w/ about speech or language delays, refer to speech therapy - for motor delay concerns, refer to pediatric neurology, physical therapy, or occupational therapy subspecialist
Warfarin: one missed dose, what to do?
take the dose as soon as possible on the same day. do not double dose the next day
Antidepressant Withdrawal Syndrome manage,ent
taper off gradually over weeks to months maybe switch short acting to longer acting such as Proazc (short acting ones are more likely to cause troublesome symptoms) - short acting ones include Effexor, Zoloft, Paxil, Celexa.
bell's palsy
temporary paralysis of the seventh cranial nerve that causes paralysis only on the affected side of the face
YAZ Black Box Warning
tenfold increase in clots in first 2 yrs (typically w/ women over age of 35
Thompson's test
test for Achilles tendon rupture by squeezing the calf while pt is prone
does antioxidant help with AMD
the available evidence does not support the use of antioxidants to prevent or delay the onset of AMD in unaffected individuals
G6PD deficiency epidemiology
the most common enzymatic disorder of RBC's, affecting 400 million people worldwide occurs most often in the tropical and subtropical zones of the Eastern Hemisphere (Africa, Europe, Asia) - Kurdish Jews 60-70 % - Nigerians - 22% - Sardinian 4-35% - thai 17% - greeks 6% - south china 6% - japan/korea 0-1 % - etc X-linked- males more likely to be affected ; females often carriers
Acute Otitis Media natural history <AOM>
the natural history of AOM in most cases is spontaneous resolution, w/ or w/o rupture of the tympanic membrane. Most of the time, a ruptured eardrum heals by itself, within hours or days. You should see your doctor about 2 weeks after your first visit so he or she can check if your eardrum has healed. If it has not, you will need to see an ear, nose, and throat (ENT) specialist. He or she might do surgery to put a tiny paper patch on your eardrum to help seal the hole. Middle effusion can persist for several months after AOM has resolved. Although uncommon, AOM can result in significant complications, such as mastoiditis, retroauricular subperiosteal abscess, septic thrombosis of the sigmoid sinus, epidural abscess, and meningitis.
phlegmon
the peripancreatic fluid collection that results from the inflammation of the pancreas
The reason why babies should receive Vitamin D
the reason that breastfed infants are deficieny in vitamin D is not b/c human milk is deficient in vitamin D per se but b/c mothers who are deficient in vitamin D have vitamin D-deficient milk, which lads to vitamin D deficiency in the infant.
Ricket def
the softening and weakening of bones in children, usually because of an extreme and prolonged vitamin D deficiency
Alopecia Universalis def
the total loss of hair on all parts of the body
Fecal Incontinence def
the voluntary or involuntary passage of feces in the underwear or in socially inappropriate places in a child w/ a developmental age of at least 4 years
COC is contraindicated in people over 35 b/c...
they contain estrogen which is contraindicated in smoker who is 35 y/o or older because increased risk of clotting disorders.
use rear facing car safety seat until...
they reach the highest wt or ht allowed by the specific seat -most seats have limits to ride for 2 years or more
use forward facing car safety seat with harness until...
they reach the ht and wt limits for the seat -most seats accommodate children up to 65 pounds or more
Patients with serious sulfa allergies should avoid _______ and ________ diuretics
thiazide and loop diuretics
HTN first line for Black population
thiazide diuretics or CCB
leukoplakia
thickened, white, leathery-looking spots on the inside of the mouth that can develop into oral cancer
work up to do on pt w/ infertility
thyroid STI pregnancy *FSH, LH, estrogen are overkills
GLP-1 receptor agonist BBW
thyroid C-cell tumors, including medullary thyroid carcinoma, due to increased incidence of these tumors in animal studies
Severe Otitis Externa Tx:
topical prep that is acidic and contains abx, antiseptic, and glucocorticoid -Cipro HC, Cortisporin *severe external otitis require placement of a wick, which allows topical med to reach the medial aspect of the ear canal and facilitates longer retention of topical solution in the affected area *Patients w/ severe disease should also have a wick placed if swelling may prevent adequate access of topical agents to the medial canal *When systemic antibiotics are necessary, we recommend a quinolone, such as ciprofloxacin or ofloxacin, for coverage of S. aureus and P. aeruginosa. Ciprofloxacin can be given at a dose of 500 mg twice daily for adults and 10 mg/kg/dose twice daily for children (maximum 500 mg/dose) for 7 to 10 days.
Permethrin AE
transient burning, stinging, pruritis
Subacute thyroiditis s/s
transient painful enlargement of thyroid gland , fever, muscle ache, w/ hyperthyroid signs and in rare occasions progress to hypothyroidism
permanent tx for androgenetic alopecia is...
transplantation surgery
how to date pregnancy if pt has irregular menses q 2-3 mths or doesn't know the first day of mense?
transvaginal US
scopolamine use
treats motion sickness crosses BBB to interact between vestibular ear and vomiting center of brain
wet prep tests for...
trichomonias, bacterial vaginosis, yeast infection
retinoblastoma def
tumor arising from a developing retinal cell
regular toilet sitting schedule
twice a day for half an hour
Rifampin vs monotherapy
tx always given in combination, not monotherapy b/c resistance develops rapidly
Iron Deficiency Anemia tx duration
tx for minimum of 3 mths (per Dr. Plato-Johnson) or until ferritin and TSAT normalize.
Seborrheic Dermatitis tx:
tx is aimed at controlling acute flares and maintaining remission w TOP antifungal or TOP steroid (group VI, VII) (med strength steroid can be used for chest or upper back) Mild Scalp: - Antifungal shampoo/cream including: (Selenium Sulfide 2.5%, Ketoconazole 2%, Ciclopirox 1%) Moderate/Severe Scalp (noted by inflammation, pruriritus, presence of scale): - Antifungal shampoo/cream + high-potency TOP corticosteroid in a formulation of pt choice used daily for 2-4 wks Face: - low potency TOP corticosteroid cream, TOP antifungal agent (ketoconazle 2% cream, other azole cream,s or ciclopirox 1), or both. TOP therapy applied QD/BID until symptoms subside Face w/ Mustache/Beard: - ketoconazole 2% shampoo on facial hair QD until remission and then once per wk - low-potency corticosteroid can be added to initial tx to control inflammation and itching Trunk and intertriginous: - TOP corticosteroid cream, TOP antifungal, or both - Medium potency TOP CS (IV or V) for chest or upper back can be used *leave shampoo on 5-10 mins before rinsing off *can be used daily or at least 2 or 3 times per week for several weeks *use of the medicated shampoo once a week may be helpful to prevent relapse *no serious AE have been reported *irritation and/or burning sensation have been reported in 1-3% of pt *some may complain of dryness of hair, which can be tx'ed w/ OTC conditioner
Methimazole use
tx's hyperthyroidism
OTC meds that may increase INR
tylenol laxative ASA IB cold medicines St. John's wort cold medicine
Eustachian Tube dysfunction dx
tympanogram
croup PE
typical findings of abrupt onset of a barking cough, inspiratory stridor, and hoarseness Respiratory rate is often increased in patients with croup The most common auscultatory finding is overt inspiratory stridor in the neck. If wheezing is present, it is typically mild; substantial wheezing should prompt evaluation for alternate diagnoses.
augmentin dosing for bacterial infx
typical: 500 mg tab (500mg/125mg) BID 7-10 days severe: 875 mg tab (875 mg/125 mg) BID 7-10days
Bacterial meningitis incubation period
typically 3-4 days (range: 2-10 days)
Herpangina incubation period
typically 3-5 days, range of 1 to 10 days
Hand Foot Mouth Disease complete resolution noted in...
typically 7-10 days
how much does baby lose wt first week to 2
typically around 10%
Rotator Cuff Tendonitis cause
typically by repetitive activities a/w overuse of the arm and shoulder, especially in physical activities such as volleyball or baseball.
Reactive Arthritis causes
typically develop one to four weeks following an acute infection with one of the triggering organisms Only certain enteric and genitourinary pathogens are conventionally accepted as capable of causing reactive arthritis. These include Chlamydia trachomatis, Yersinia, Salmonella, Shigella, Campylobacter, Clostridioides (formerly Clostridium) difficile, and Chlamydia pneumoniae. Various other bacterial and viral infections have been suggested as triggers for postinfectious arthritis but they are by convention not considered as "reactive arthritis."
Intussusception clinical manifestations
typically first finding may be sudden loud crying caused by abdominal pain. -pain is intermittent q 15-20 mins in the beginning. Painful episodes become longer and more frequent as time passes. -stool mixed with blood and mucus (red currant jelly) -N/V -lethargy -diarrhea -fever -palpable sausage shaped mass may be felt in the right side of abdomen -child may draw his knees up toward the chest
Ganglion cyst s/s
typically found on the dorsal side of the wrist; may be tender to paplpation, mobile, and transilluminates may be accompanied by the coolness of the hand, numbness/tingling, and possible paresthesias
RSV s/s
typically occurs during RSV season (November through April) Younger children (< 5 y/o): - prodrome of URI, nasal discharge, mild fever, dyspnea, non-productive cough, tachypnea with nasal flaring, retractions and possible wheezing -worsens on days 2-3 (demonstrates tachypnea and wheezing three to five days after coming down with the cold) -llness usually runs its course in 7-14 days. older children: may have only runny nose and mild cough
Mongolian spots can be found in...
typically on... - Lumbosacral area - back - scalp - anywhere on the skin
Hand-Foot-Mouth Disease s/s
typically presents w/ mouth or throat pain (verbal children) or refusal to eat ( nonverbal children) 1. fever (occasional) typically less than 101 F; (often the first sign of hand-foot-and-mouth disease, followed by a sore throat and sometimes a poor appetite and malaise) 2. sore throat 3. vomiting 3. sometimes vesicular lesions located on the oral mucosa, hands, and feet; oral manifestations may be small, red papules on the tongue, and buccal mucosa that progress to ulcerative vesicles on an erythematous base (1-2 days after the fever begins, painful sores may develop in the front of the mouth or throat. A rash on the hands and feet and possibly on the buttocks can follow within one or two days.) 4. associated rash (macular, maculopapular); exanthum occurs 1-2 days after oral lesions; RARELY PRURITIC; may occur on the palms, soles, arms, legs, buttocks, fingers, and toes 5. 25% have enlarged anterior cervical nodes or submandibular nodes *The skin lesions of HFMD are typically NONPRURITIC. They usually are not painful, but may be painful when HFMD is caused by certain serotypes (eg, coxsackievirus A6). The lesions typically resolve in 3 to 4days
Trichomoniasis transmission route
typically sex but can also be thru formites, swimming pools, hot tubs *will typically occur w/ other STI's
how well does buckle fracture heal
typically very well
how is ADHD dx'ed
ultimately DSM criteria will be used to confirm the dx after comprehensive exam
Degludec is...
ultra long acting insulin
Crohn's: pain location
umbilical region and RLQ q HS
bartholin gland cyst cause
uncertain cause: in rare cases, may be du/t STI like gonorrhea or chlamydia
Interstitial Cystitis patho
unclear it's either localized condition involving the bladder or systemic disease affecting the bladder
Irritable Bowel Syndrome patho <IBS patho>
unclear but... abdominal pain seem to be due to visceral hypersensitivity constipation and diarrhea seem to be d/t abnormal bowel motility
Amytrophic Lateral Sclerosis patho
unclear patho, there are several theories progressive, degenrative motor neuron disease: upper, lower motor neuron signs it is possibly due to protein aggregation in side neuron that causes injury and death that lead to retrograde neuronal degeneration
Multiple Sclerosis cause
unclear, it is autoimmune causing death of oligodrocyte
Effexor contraindications
uncontrolled angle closure glaucoma
Listeria food
unheated processed/deli meats hot dogs soft cheeses (feta, brie) smoked seafood meat spreads/pate
aphthous stomatitis cause
unknown
Polymyalgia Rheumatica patho
unknown seems to be autoimmune the term polymyalgia implies a myopathic process, but the muscles in PMR is histopathologically normal.
Acute sinusitis lasts
up to 4 wks
the most common physiological location of a TB infx <tuberculosis>
upper lobes (typical findings are cavitation (round black holes due to local loss of lung tissue), fibrosis, lymphadenopathy, and calcifications.)
hyperuricemia def
urate lvl >= 7 mg/dL
Smoker + RBC per hpf on U/A : what would you be concered about?
urothelial malignancy
Pull test is used for what? how is it done?
used for Telogen Effluvium dx no shower for 24 hrs, grasp about 60 hairs, if >= 6 hairs out, + for telogen effluvium
Amsler Grid is used for
used to find age-related macular degeneration
Mononucleosis cause
usually EBV, which binds to CD21 receptors on B cells
Diverticulosis s/s
usually asymptomatic sometimes stomach pain (LLQ) and bleeding thickened palpable sigmoid and descending colon possible bloating often found incidentally while examining pt no inflammation or bleeding
Herpangina transmission
usually from person to person by the fecal-oral route can also be transmitted by contact with oral and respiratory secretions
HFMD dx
usually is made clinically, based upon the typical appearance and location of the oral enanthem and exanthem Confirmation of a specific viral etiology is seldom necessary in children with uncomplicated HFMD or herpangina, but may be warranted if the diagnosis is uncertain (eg, isolated exanthem) and would affect management (eg, atypical HFMD versus eczema herpeticum) and in children with complications. When etiologic confirmation is necessary, throat, stool, and vesicular fluid samples should be obtained for viral culture or nucleic acid amplification (eg, polymerase chain reaction) [75]. For samples from all sites, nucleic acid amplification is preferred to cell culture because of increased sensitivity and the speed with which a result can be obtained (hours versus days)
hand foot mouth disease contagious period
usually most contagious during the first week that they are sick. People can sometimes spread the virus to others for days or weeks after symptoms go away or if they have no symptoms at all.
Inevitable Abortion definition
usually presents w/ painful cramps, increasing bleeding, and dilated cervix w/ gestational tissue often visible at the cervical os. A D&C is indicated for significant cramping or blood loss.
Incomplete Abortion definition
vaginal bleeding and/or pain w/ dilated cervix loss of some of the products of conception occurs, with part of the products retained (most often the placenta)
Valproate in pregnancy concerns
valproate increases risk of neural tube defects by inhibiting materal folate absorption *should be avoided and only prescribed if no other AED is effective for that particualr pt
musculoskeletal chest pain duration and characteristic
variable duration superficial, positional, worse w/ movement, local tenderness
fungi would be what color under wood lamp
variation of green or bluish tinge
Raynaud Phenomenon symptoms stages
vasoconstriction of arteries near the skin turns skin white -> blue -> red
Gout epidemiology
very common (20-25% of adult men, can begin at puberty) Men > women *smaller proportion of women, generally delayed until menopause (d/t estrogen efx)
Ketorolac vs other NSAIDs
very potent, available for parenteral use, IV, IM short-term management of acute moderate pain AEs hematologic AEs- use limited to 5 days
Indomethacin vs other NSAIDs
very potent, greater AE's used for moderate-severe acute inflammatory conditions used in infants for patent ductus arteriosus
Hives key defining features
very quick to appear, very quick to disappear, disappears within 24 hours
Sinusitis most common cause
viral - rhinovirus - parainfluenza virus *above 2 cause common cold - influenza
gastric ulcer pain worsens w/ or w/o meal
w/ meal
duodenal pain worsens w/ or w/o meal
w/o meals
Chlamydia urethral discharge
watery clear urethral discharge
Positive Trendelenburg Test suggest
weakness in the hip abductor muscles: gluteus medius and gluteus minimus
when to use belt-positioning booster seat
when child exceeds the limit for forward facing car safety seat use belt-positioning booster seat until they can properly fit in to the vehicle's seat belt -often until they have reached at least 4 '9" ht and are 8 - 12 y/o
pediatric: when to initaiteve preventive migraine tx
when headaches are frequent, prolonged, or disabling or when preventive therapy is used when pts fail to respond or are intolerant of acute tx
Gout: pt on NSAID, when would you reduce the dosage
when pt first experiences significant reduction in symptoms, but frequency of dosing should continue
when to initiate evaluation of hyperuricemia...
when urate lvl is 8 mg/dL or higher
IUD insertion easier during what phase of menstrual cycle
while you are on period
Tamiflu when to take? why take?
within 48 hr -Antiviral drugs work best when taken within 48 hours of onset of flu symptoms, but they may still offer benefits when taken later
Toxoplasmosis clinical manifestations
women: fever, fatigue, muscle pain, maculopapular rash infants: symptoms only present in minority of cases; 55-85% develop classic triad of chorioretinitis, hydrocephalus, intracranial calcification; decreased birth wt, learning disability, jaundice also possible
bile acid sequestrants clinical pearls
work in the GI tract to decrease absorption. these meds are not as effective at lowering LDL as statins, but may be a good alternative for those who cannot tolerate statins or other meds.
Multiple Sclerosis s/s
worsens over wks, lingers for mths symptoms may flare up at certain pts, and then the pt may go for mths w/o any symptoms at all. Symptoms are diverse... Charcot's Triad - Dysarthria (d/t plaques in brainstem which also interfere w/ conscious movements such as eating/talking and unconscious movements such as swallowing) - Nystag mus (d/t plaques in nerves of eyes which also cause optic nerve damage that lead to loss of vision; if there is damage to the nerve innervating ocular movement, there may be pain w/ movement or diplopia - Intention tremor (d/t plaques along motor pathways which can also cause muscle weakness, spasms, tremors, ataxia, paralysis) Other areas... -Plaques in sensory pathways from skin (numbness, paresthesia) -Plaques in atuonomic nervous system (bowel and bladder symptoms, sexual dysfunction) - higher oder activities (poor concentration, critical thinking, depression, anxiety)
Metformin vs weight
wt loss (useful in overweight or obese pts)
G6PD is what kind of genetic disorder
x linked recessive (boys affected, not girls)
nystatin and amphotericin B are active against ____________ but not ______________
yeast infx, but not dermatophytes
Carotenemia vs jaundice
yellow discoloration of the skin sparing the sclera is the key feature that distinguishes carotenemia from jaundice.
is MMR live vaccine
yes
does OA pain worsen w/ activity?
yes, and lessens w/ rest
is yellow fever vaccine live?
yes, it is live, but can be used in some pregnant females
INH take on empty stomach?
yes, take 2 hrs before/after meal
BP goal per JNC8
• In patients 60 years or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now <150/90 mm Hg. • In patients 18 to 59 years of age without major comorbidities, and in patients 60 years or older who have diabetes, chronic kidney disease (CKD), or both conditions, the new goal blood pressure level is <140/90 mm Hg.
rapid acting insulin list (3)
• Lispro (Humalog) • Aspart (Novolog) • Glulisine (Apidra)
Carotene sources
• Red, orange, yellow, deep green • Carrots, sweet potatoes, pumpkin, spinach, broccoli
bipolar disorder diagnostic criteria
■ Characterized by episodes of Major Depression and Mania ■ Manic episode: At least 1 week of persistently elevated, expansive or irritable mood, including at least 3 of the following: - Inflated self-esteem or grandiosity - Decreased need for sleep - Pressured speech - Racing thoughts - Distractibility - Increase in goal-directed activity or psychomotor agitation - Excessive involvement in high-risk pleasurable activities
Aphthous stomatitis ulcer morphology
●Minor ulcers, <1 cm in diameter, usually 3 to 5 mm ●Major ulcers, >1 cm in diameter ●Herpetiform ulcers, 1 to 2 mm in diameter, typically present in clusters, sometimes coalescing in larger ulcer
Acute Bacterial Rhinosinusitis def
●Persistent symptoms or signs of ARS lasting 10 or more days without evidence of clinical improvement or ●A biphasic pattern of illness, typically extending over a 10-day period, characterized by signs and symptoms of ARS that initially start to improve but then worsen approximately five to six days later ("double worsening").
Stages of Changes
●Pre-contemplation (not ready to quit) ●Contemplation (considering a quit attempt) ●Preparation (actively planning a quit attempt) ●Action (actively involved in a quit attempt) ●Maintenance (achieved smoking cessation)
Latent TB tx of choice in low-incidence setting: <tuberculosis>
●Rifampin (RIF) daily for four months (regimen abbreviation: 4R) ●Isoniazid (INH) and RIF daily for three months (regimen abbreviation: 3HR) ●INH and rifapentine (RPT) weekly for three months (regimen abbreviation: 3HP) ●INH daily for nine months (regimen abbreviation: 9H) *We favor 4R b/c of greater adherence and less hepatotoxicity
Encapsulated organism mnemonic
"Claustrophobic Pastor Salmon Echoed Back: Yersinful Crypt-dark Strip Clubs are Pseudo-Homes to Nice Men Francis and Bruce" Claustrophobic: clostridium Pastor: Pasturella Salmon: Salmonella Echoed: E. coli Back: Bacillus anthracis Yersinful: Yersinia Crypt-dark: cryptococcus Strip: streptococcus Clubs: Klebsiella Pseudo: Pseudomonoas Homes: Haemophilus Nice men: Neisseria meningitidits Francis: Francisella Bruce: Brucella
Rheumatoid Arthritis pathophysiology
"Complicated"... - multiple genetic, environmental, immunologic, and other factors contribute to the development and expression of disease the resulting inflammation thickens the synovium, which can eventually destroy the cartilage and bone within the joint
Anticholinergic overdose s/s
"dry as a bone, red as a beet, mad as a hatter, blind as a bat" - flushing - fever - urinary retention - delirium/hallucinations - mydriasis (pupillary dilation)
COPD tx for group B
(SABA OR SABA/SAMA combo (if taking LABA)) + (LABA or LAMA) - LABA- Salmeterol (most studied), Formoterol, Arformoterol, Indacaterol, Vilanterol, Olodaterol - LAMA- Tiotropium (most studied), Aclidinium, Umeclidinioum, Glycopyrrolate *LABA monotherapy in COPD is not associated with increased risk of respiratory mortality
Baker Cyst tx
(UTD) Asymptomatic cysts found incidentally do not require tx. - advise patients with asymptomatic cysts that there is a small risk of future cyst rupture. Pts should return if a cyst becomes symptomatic and should promptly seek further medical attention if they develop s/s of the pseudothrombophlebitis syndrome. General measures: - in all pts w/ symptomatic cysts, tx any underlying joint disorder (OA, RA, meniscal injury) Initial Therapy: - tx adult pts w/ symptomatic painful cysts w/ or w/o calf involve w/ arthrocentesis of the knee and intraarticular injection w/ glucocorticoid (40 mg triamcinolone acetonide), using the same approach as that of OA or RA. *tx in pediatric population is unnecessary , and most cysts in children resolve completely without treatment. Children are often managed in collaboration with an orthopedic surgeon.
Folate Deficiency Anemia s/s
(almost same as B12 deficiency) - glossitis - leg edema - anorexia - diarrhea - DOE -*no neurologic sequelae -*if in pregnant mom: neural tube defect
Copper IUD side effects
)heavier menstrual bleeding by up to 50% (Copper IUD specific) Worse menstrual cramps (Copper IUD specific) irregular periods (can throw off your menstrual cycle. At first, your periods may be heavier than usual. Eventually, the bleeding should get lighter and fewer menstruation). spotting between periods cramping or backaches for a few days after the IUD is put in
Carotid Artery Stenosis dx
* There are no externally validated, reliable tools that can determine who is at increased risk for carotid artery stenosis or for stroke when carotid artery stenosis is present. PE: - Auscultation (Adequate evidence indicates that the accuracy of screening by auscultation of the neck is poor) Diagnostic Studies: - Noninvasive Duplex studies (high quality sonogram + Doppler) (In practice, ultrasonography yields many false-positive results in the general population, which has a low prevalence of carotid artery stenosis (approximately 0.5% to 1%).) - MRA (Carotid magnetic resonance angiogram) - CTA (Computed tomographic anigoraphy) - Cerebral angiography w/ contrast
Myocardial Infarction atypical presentation
* Up to 1/3 of pts may not present w/ chest pain on presentation to the hospital * they are more likely to be older, diabetic, and women - Dyspnea - Weakness - N/V - Epigastric pain or discomfort - Palpitations - Syncope - Cardiac arrest
CCB vs angina clinical pearls
*- all CCBs are effective in the tx of stable angina pectoris. * - Combo therapy w/ CCB + BB is more effective than monotherapy w/ CCB. -Use Amlodipine or Felodipine before other CCB, given their better SE profiles when used in combo w/ BB's - CCB, particularly Verapamil and Diltiazem, should be used w/ caution in pts w/ L ventricular systolic dysfunction, such as those w/ ejection fraction less than 40 percent or HF d/t their negative inotropic efx. - The preceding findings and other studies suggest AE on CV pts in pts tx'ed w/ short-acting dihydropyridine and high doses of Diltiazem and Verapamil.
Neonatal sepsis s/s
*-temp instability (fever)* *-irritability* *-poor feeder* -suspicious drainage -vomiting/diarrhea -poor weight gain -abd distention -apnea/sternal retractions/grunting/nasal flaring -decreased O2 saturations -pallor -tachycardia or bradycardia -tachypnea -low bp -poor muscle tone
GLP-1 receptor agonist SE
*1. N/V/D (very common)- nausea may be severe enough that a patient has to stop taking the drug. 2. hypoglycemia possible when combined w/ some PO DM meds 3. pancreatitis (rare) 4. nephrotoxicity 5. avoid in pregnancy
Type 2 Diabetes Mellitus A1C goal, glucose goal:
*No single goal is right for everyone* elderly patients have laxer goal A1C - <7% (per ADA) - <=6.5% (per AACE 2020) - > 6.5% for pts w/ concurrent serious illness and at risk for hypoglycemia - An A1c goal of between 7% and 8% is reasonable and beneficial for most patients with type 2 diabetes though if lifestyle changes can get that number lower, then go for it. If on insulin: - fasting, premeal BG < 70-110 mg/dL (less aggressive 90-130) - 2 hrs postprandial < 180 (less aggressive 140) - absence of hypoglycemia signs
Diverticulitis tx (outpatient management)
*Patients who fail the following outpatient treatment are admitted for inpatient treatment. 1. clear liquid diet for 48-72 hrs then move up to low-residue diet 2. 7-10 days broad-spectrum antibiotics to limit bacterial growth - Cipro + Metronidazole - Augmentin - Bactrim + Metronidazole - Moxifloxacin 3. analgesics - start w/ tylenol then up to tramadol if it doesn't work - Acetaminophen 500 mg 1-2 tabs q 4-6 hrs, no more than 4 grams/day 4. high-fiber diet after acute phase (prevention) - UTD: in order to prevent recurrence, pts w/ a hx colonic diverticulitis should consume a high-fiber diet. Study shows long-term fiber supplementation may reduce the incidence of recurrent diverticulitis. - *NO NEED TO AVOID SEEDS, CORNS, AND NUTS- this is completely unproven. Study showed they did not increase the risk of developing diverticulitis or its a/w complications (eg bleeding) 5. Misc medical methods: - No need for mesalamine: mesalamine used to be used to tx diverticulitis. No evidence of effx noted in studies. - Probiotics: there is even less evidence to support the use of probiotics - No evidence of rifaximin helping 5. surgery (severe)
Hidradenitis suppurativa -nonpharmacologic management (4) -pharmacologic/surgical management (6)
*REFER TO DERM* Nonpharmacologic management - wt lose - smoking cessation - frequent cleaning - loose fitting clothes Pharmacologic/surgical management (depends on Hurley Stages) - abx (TOP Clindamycin often used as first line tx for mild HS; PO Doxy 100 mg PO QD/BID for moderate to severe HS first line) - Intralesional steroids - traditional surgery possible - CO2 laser surgery possible - monoclonal ab therapy possible - isotretinoin
Irritable Bowel Syndrome risk factors <IBS risk factors>
*Risk factors are also triggers in many pts 1. Gastroenteritis can cause post-infectious IBS (PI-IBS) - Norovirus - Rotovirus 2. Stress 3. female (in US) 4. age (more likely to affect those in teen through their 40s) 5. psychiatric disorders 6. food sensitivity
Malaria Prophylaxis
*TDLR: just use Doxycyline 100 mg PO QD start 1-2 days before exposure; d/c 4 wk after exposure For travelers to destinations where malaria cases occur only sporadically and risk to travelers is very low, no chemoprophylaxis is needed. For travelers at risk of malaria infx where chloroquine-resistant P. falciparum malaria is present - atovaquone-proguanil, mefloquine, doxycyline, and tafenoquine all found efficacious. For travelers at risk of malaria infx where chloroquine sensitive P. falciparum malaria is present, chloroquine may be used (*Mefloquine and doxycyline are also effective agents)
Irritable Bowel Syndrome dx <IBS dx>
*absence of abdominal pain can be used to r/o IBS *routine blood and stool studies are not recommended in IBS dx *routine testing for celiac disease should be considered in pts w/ diarrhea-predominant or mixed presentation IBS 1. Complete hx and PE -*exam findings often found normal 2. Rome IV Criteria - recurrent abdominal pain, on average, at least 1 day/wk in the last 3 mths, a/w 2 or more of the following criteria: related to defecation; a/w a change in stool frequency; a/w a changei n stool form (appearance) 3. In all pts w/ suspected IBS, perform CBC and age appropriate colorectal cancer screening 4. In pts w/ diarrhea, perform the following: - fecal calprotectin or fecal lactoferrin (fecal calprotectin > 50mcg/g has a pooled sensitivity and specificity for IBD of 81 and 87 % respectively. Lactoferrin above range of 4-7.25 mg/g have sensitivity and specificty of IBD of 79 and 93 % respectively) - stool testing for giardia - serologic testing for celiac disease - CRP level only if fecal calprotectin and fecal lactoferrin cannot be performed (IBS does not cause inflammation; CRP will be elevated in IBD but not IBS)
Macular Degeneration s/s
*changes in central vision, blank spot in central vision, distorted appearances* Lack of depth perception Objects appear distorted Blurred vision Blindness
Psoriasis PCP management
*dermatology referral!!!* Adult initial therapy: - Adult initial therapy: medium-potency corticosteroids daily: 0.1% mometasone or triamcinolone; strong-potency corticosteroids: 0.05% betamethasone or fluocinonide daily; superpotency corticosteroids: clobetasol, halobetasol; caution with use over 2 to 4 weeks; avoid occlusive dressings; reserved for recalcitrant plaques - Vitamin D (Calcipotriene) - Emollient (petrolatum/ointments) pharm: -TOP corticosteroid (mainstay)- *potent steroid combined w/ Vit D analogue (Calcipotriene)* (ointment preferred over cream) steroid applications are typically twice daily until lesions flatten/resolve and then taper to PRN use for maintenance. -step up therapy is in purview of dermatologist- consult w/ derm -Emollients: petrolatum/ointments to maintain skin hydration and minimize pruritus and risk of koebnerization Corticosteroid per area - Scalp or external ear canal: potent corticosteroid in solution/foam vehicle; shampoos and sprays also available (e.g. fluocinonide 0.05 %, Clobetasol propionate 0.05%) - Face and intertriginous area: low-potency ointment (OTC hydrocortisone 1%, hydrocortisone 2.5% <prescription strength>) often sufficient - Thick plaques on extensor surfaces, potent prep (e.g. betamethasone 0.05% or clobetasol propionate 0.05%) *Calcipotriene-Betamethasone DP available but is expensive (400$) *A reasonable approach to combination therapy is to have patients apply topical calcipotriene and topical corticosteroids each once daily at different times of day.atop
Initial tx for most pts w/ Type 2 Diabetes and A1C at or above target level:
*for those w/ clear and modifiable contributors to hyperglycemia and are motivated to change, 3 mth trial of lifestyle mods prior to pharm initiation is warranted Mainstay: pharmacologic therapy should be initiated at the time of T2DM dx (w/ lifestyle mods) Entry A1C < 7.5% - Monotherapy (metformin, GLP-1 RA, etc) Entry A1C > 7.5% - dual or triple therapy Entry A1C > 9 % w/o symptoms - dual or triple therapy Entry A1C > 9% w/ syptoms - insulin +/- other agents
First Generation Antipsychotics adverse effects
*greatest incidence of extrapyramidal motor manifestations. - Akathisia, pseudoparkinsons, dystonia - Worse case: tardive dyskinesia (abnormal oral and facial movements)- poorly reversible Greatest incidence of hyperprolactinemia - Male gynecosmastia, female menstrual irregularities Risk of neuroleptic malignant syndrome
Diverticulitis s/s
*is always symptomatic - Acute crampy onset of LLQ pain in 85% cases - Tenderness to palpation on PE - N/V - Constipation/diarrhea - Low grade fever - Chills - Tachycardia - ESR & WBC increased (sign of infection) - Hgb & Hct decreased - *not a/w bleeding because blood vessels scarred from inflammation
Acute otitis media common causes:
*often a/w viral URI* Viral (30-70%) - RSV - rhinovirus - coronavirus - influenza, parainfluenza Bacterial (55%) - Strep Pneumoniae (44%) - H Influenzae (41%) - Moraxella Catarrhalis (14%) - gram negative enteric bacteria - S. aureus
acute angle closure glaucoma
*sudden unilateral eye pain* *redness* *Mid-dilated pupil (4 to 6 mm) w/ poor light response* *Blurred Vision* *Headache* *Halos around lights* *Nausea* *Vomiting* *colored halo around lights due to corneal edema *
Oropharyngeal candidiasis tx
*try TOP antifungal rather than systemic TOP: - Clotrimazole troches (one 10 mg troche dissolved slowlty 5 times daily) may be difficult to adhere d/t frequent dosing - Nystatin swish and swallow 400,000 to 600,000 units QID 4-6 mL retain for as long as possible for 7-14 days (has sucrose which can cause dental caries when used over prolonged time period) SYSTEMIC: - fluconazole 200 mg PO then 100 to 200 mg daily for at least 2 wks "Azole" medications are pregnancy Category C. - do pregnancy test
Rotarix - protects against how many strains? - dose sched
- 1 (monovalent) - 2, 4 mths
intermediate acting insulin: onset, peak, duration of action
- 1-2 hr - 4 hrs - 16-24 hrs
long acting insulin -onset -peak -duration of action
- 1-2 hr - NO PEAK - 24 hrs (Glargine); 20 hrs (Detemir)
Degludec - onset - peak - duration of action
- 1-2 hr - no peak - 48 hrs
Autism first tier screening tool
- 16-30 mths: M-CHAT - 4 yrs and up : SCQ (Social Communication Questionnaire) - 7-16 yrs: ASSQ
short acting insulin,. onset, peak , duration of action
- 30 mins - 2-3 hrs - 5-8 hrs
Rotateq - protects against how many strains? - dose sched
- 5 (Pentavalent) - 2, 4, 6 mth
Rapid acting insulin: onset, peak, duration of action
- 5-15 mins - 1 hour - 3-4 hrs
Chronic Cough most common causes
- Asthma - Upper airway cough syndrome (postnasal drip) - GERD - chronic bronchitis - Smoking and other irritants - Meds - Perennial rhinitis
when does jaundice go away
- Breastfed babies, common for jaundice to last 1 month or occasionally longer. - Formula-fed babies, most goes away by 2 wks. However, if more than 3 wks, see doctor
CCB vs HFpEF
- CCB may be useful in tx of HTN in pts w/ HFpEF, though the evidence is very limited - *CCB is 3rd or 4th line antihypertensive in HFpEF pts w/ severe HTN* -* tx of HFpEF is largely governed by management of associated conditions and symptoms since there is limited direct evidence to support a specific drug regimen.
osteoporosis screening guideline
- DXA Scan if age >=65 y/o - DXA Scan if age < 65 w/ risk factors (advancing age, previous fracture, glucocorticoid therapy, parental hx hip fracture, low body wt, current smoker, excessive ETOH consumption, rheumatoid arhtirtis, secondary osteoporosis)
primary prevention examples
- Discuss a low-fat diet and the need for regular physical exercise with clients. - when a nurse provides health education and training for daycare workers about issues of health and hygiene, such as proper hand hygiene, diapering, and food preparation and storage - Immunizations, importance of wearing seatbelts, taking folic acid supplementation at preconception to prevent neural tube defects, fluoridation of water supplies to prevent dental caries, and actions taken to reduce human exposure to agents that may cause cancer - Implement a community level program like walking for exercise to assist citizens in improving health behaviors related to lifestyle. - Use the Code of Ethics for Nurses to guide your nursing practice - Use the information exchange process to increase the client's understanding of how to use the health care system and the health promotion strategies that will maintain health. - Complete a family genogram and assess health risks with the family to contract for family health activities to prevent diseases from developing
Nicotine withdrawal symptoms
- Dysphoria or depressed mood - Wt gain / icnreased appetite (4 to 5 kg over 10 years) - Insomnia - irritability, frustration, or anger - Anxiety, restlessness and difficulty concentrating - Decreased heart rate and increased appetite or - Headache, - increased appetite, - Inability to concentrate - Decrease in heart rate and blood pressure
sulfa abx AE
- GI intolerance - hypersensitivity ( worst case: Stevens-Johnson syndrome) - anemia + neutropenia (needs CBC) - elevated K+ - elevated creatinine (dose adjusted for GFR) -is oxidizing drug (watch in G6PD deficiency)
long acting insulin list
- Glargine (Lantus) - Detemir (Levemir)
how can pregnancy cause UTI
- Hormonal and mechanical changes of pregnancy - difficulty with hygiene d/t distended pregnant belly *UTI are among the most common bacterial infx during pregnancy
Spironolactone AE
- Hyperkalemia (in patients w/ ACEi and ARBs) - GI disturbances -Endocrine (gynecomastia, decreased libido, menstrual irregularities)
Sulfonamides adverse effects
- Hypersensitivity reactions: Stevens-Johnson syndrome - Hematologic effects - Kernicterus - Renal damage from crystalluria
Measles Tx
- ISOLATE! - Supportive interventions (hydration, pain relief, fever relief) - Superinfx Tx - Vit A (boosts AB response, decreases risk of complication)
Aldosterone antagonist lab works
- K+ - CRE
MRI vs CT
- MRI: strong magnetic field, more detail because of better resolution than CAT scan; better for soft tissues - CT Scan: x-rays, less costly and less time; better for bones
Medial Tibial Stress Syndrome vs Medial Tibial Stress Fracture differentiation
- MTSS pain is more diffuse (tenderness to palpation all along the medial aspect of tibia); MTSF is pinpoint w/ edema - Plain film may not encapture the fracture first 4 wks (MRI is more sensitive). Plain radiographs are normal in patients with shin splints, but may also be unrevealing early in the course of a stress fracture. - they are both caused by exercising too much, too soon - a runner with a stress fracture should avoid running and pursue non-impact activities like swimming or cycling while the stress fracture heals, while the runner with MTSS can continue running but should reduce the total mileage. A systematic review found that shock-absorbing insoles may reduce symptoms and prevent recurrence of MTSS
Verapamil clinical pearls
- May be used to treat arrhythmia - avoid in HF - Effective in angina b/c it decreases myocardial oxygen demand by acting as a negative inotrope and chronotrope and lower systemic BP - Can exacerbate HF in pts w/ cardiac dysfunction d/t its negative inotropic activity, this efx is more pronounced w/ BB, a combo that is not generally used - Also slows cardiac conduction; may be deleterious in pts w/ sinus node dysfunction or AV block; - Much less potent vasodilator than dihydropyridines, as a result SE are less common - Should be avoided in pts w/ left ventricular ejection fraction < 40%
Diltiazem clinical pearls
- May be used to treat arrhythmia - avoid in HF - Dilitiazem has actions that fall between the dihydropyridine and Verapamil -Potent coronary but a mild arterial vasodilator, producing improved blood flow through coronary epicardial vessesl, collaterals, and normal and ischemic myocardium, as well as lowering MAP - May depress sinus node automatically and AV nodal conduction time but this efx is less prominent than that seen w/ Verapamil - Diltiazem is a negative inotrope. - *The net efx is that diltiazem may be somewhat better tolerated than the other CCB's, since it is neither a potent vasodilator nor a myocardial depressants.
Nasal Decongestants
- Oxymetazoline (Afrin, Neo-Synephrine nighttime 12-hour) - Naphazoline (Privine) - Phenylephrine (Neo-Synephrine 4 hours) - Tetrahydrozoline (Tyzine) > Rx CI - Hypertension, V-tachycardia Notes - Limit use to <= 3 days to prevent rebound congestion
Atrovent Nasal Spray is used for
- Perennial Allergic/Nonallergic Rhinitis - Symptomatic relief of rhinorrhea (Common Cold)
DMARD diagnostic testing prior to putting pt on it
- TB (PPD) - Hep B/C - HIV - Baseline liver enzymes, renal function, lipids, CBC, ESR, CRP - Ophthalmic screening for hydroxychloroquine (Plaquenil) risk for ocular toxicity (chloroquine retinopathy)
depression diagnostic tests
- TSH, free T4 (hypothyroidism) - CBC, folate, B12, ferritin, iron, TIBC - drug screening (substance use, alcohol use) - HIV - Hepatitis - medication use: BB, corticosteroid - r/o DM (Hba1c), cancer, heart, SLE - BMP/CMP (metabolic panel to r/o organic causes)
Thrombotic Thrombocytopenic Purpura patho
- Thrombotic microangiopathy caused by deficient activity of ADAMTS13 protease - aDAMTS13 breaks von Willebrand factor molecules into smaller multimers, prevents excessive accumulation on endothelial surfaces in microvasculature - Excessive vWF on endothelial surfaces -> increased propensity for plts to attach, accumulate (esp. in high pressure areas w/ shearing stress) + endothelial damage -> plt-rich thrombi in microcirculation -> tissue ischemia, organ ysfunction, microangiopathic, hemolytic anemia, thrombocytopenia - Thrombocytopenia consumptive (increased need for plts rom cyclical clot formation, dissolution) - Microangiopathic hemolytic anemia - RBC mechanical fragmentation in microthrombi, damaged vessels -> schistocytes - Organs most affected: brain, heart, adrenal glands, pancreas
Combo therapy CCB + BB clinical pearl
- Verapamil + BB may be the most effective combo but is a/w highest incidence of significant SE d/t negative and additive inotropic and chronotropic actions of both drugs - Nifedipine- combo of Nifedipine + BB is a/w fewer SE but is also less efficacious than the other combos.
nasal polyp tx
- abx - po coritocsteroid - antihistamine - nasal spray
Lyme disease dx:
- assess for typical clinical finding (Erythema Migrans if early stage, other clinical findings like fatigue, muscle aches, arthralgia, fever) - if no EM but other clinical findings noted for high risk pts, perform 2 tiered serologic testing
fluoroquinolone list
- ciprofloxacin (Cipro) - levofloxacin (Levaquin/Quixin) - gatifloxacin (Tequin) - moxifloxacin (Avelox) - ofloxacin (Ocuflox/Floxin/Floxacin) - norfloxacin (Noroxin)
HTN initial workup
- electrolyte, serum CRE, eGFR - fasting glucose (a/w dm) - urinalysis (check protein) - lipid profile - ECG
tertiary prevention examples
- enhance rehabilitation from disease, injury, or disability - Provide cardiac rehabilitation, medication, and surgery. - medical treatment - physical and occupational therapy, and rehabilitation - Monitor the use of prescription medications and adherence to treatment to reduce risk for illness complications - Provide health promotion activities to persons with serious and persistent mental illness. - Promote support group participation for those with mental health disabilities. - The public health nurse provides a diabetes clinic for a defined population of adults in a low-income housing unit of the community. - If blood pressure cannot be controlled by diet, refer the client to a physician or nurse practitioner for medication; advise the client to engage in a cardiac program that will oversee diet and exercise. - Participate in home visits to mothers who are at risk for neglecting babies, to reduce the costs related to abuse - Provide health care and treatment for those infected by H1N1 or the new strains of the virus. - Evaluate the incidence or prevalence of obesity among school children after the implementation of the program and provide programs to reduce complications from the condition. - A review of the public health report card indicated that community incidence of complications from vaccine-preventable diseases have declined over a 2-year period after the implementation of the parent education program. - Provide family therapy for abusive families; remove children from the home. - Develop a contract with the family to change nutritional patterns to reduce further complications from the specified health problem. - Provide directly observed medication therapy for people with active TB. - Develop programs to help people reduce or end substance abuse - Regular inspection of hands and feet, as well as using protective footwear and gloves to avoid trauma and infection for leprosy clients who have lost sensation in those areas- developing an individual education plan (IEP) for students with long-term health needs - developing an individual education plan (IEP) for students with long-term health needs
Infectious Mononucleosis s/s
- fever - sore throat - pharyngeal inflammation and tonsilar exudates often accompany sore throat (may appear white, gray-green. or even necrotic) - swollen cervical lymph nodes - fatigue (PERSISTENT) - increased lymphocyte count - activated lymphocytes - splenomegaly (seen in 50-60% of pt w/ IM and usually recede by 3rd wk of illness) - rash (generalized maculopaular urticarial or petechial rash occasionally seen following ampicillin or amoxicillin)
Rifampin AE
- hepatitis- check LFTs, avoid alcohol - hypersensitivty- in up to 50% of pts, presents as flu-like illnesses - kidney disease, leukopenia, thrombocytopenia
Aldosterone antagonist side effects
- hyperkalemia - gynecomastia with spironolactone in men and decreased libido in women
metronidazole DI
- increases anticoagulant action of warfarin - gives disulfuram-like reaction to alcohol
Yellow Fever vaccine contraindications
- individuals w/ allergy to vaccine ingredients (allergy to vaccine ingredients eggs, gelatin, chicken proteins) - immunodeficiency *can be used in pregnant females even though it's live
Latent TB monitoring <tuberculosis>
- mthly LFTs for pts at high risk for INH hepatitis - s/s liver damage
Buspirone SE
- nausea - restlessness *- SEDATION* - HEADACHE - nervousness - DIZZINESS
when would diuretics fail
- not adhering to sodium restriction - drinking too much fluid - not enough diuretics
Polymyalgia Rheumatica pain progression...
- onset can be abrupt, sometimes, startlingly so, seemingly occur almost overight - pain/stiffness of shoulder or hip starts on one-side, but progresses to both sides within weeks - symptom more severe at morning and night, often lasting more than an hour
Ethambutol AE
- optic neuritis-> decreased visual acuity, color blindness, central scotoma - hyperuricemia, gout - hepatitis - thrombocytopenia
citalopram side effects
- palpitations - tachycardia - N/V - diarrhea - decreased appetite - nervousness - insomnia - SEDATION/DROWSINESS - hyponatremia
Metformin contraindication
- renal / hepatic patients (this is how it is excreted, can cause lactic acidosis) - cimetidine (decreases excretion of metformin, resulting in increased exposure of Metformin and elvated risk of Lactic Acidosis) - furosemide (increases effx of metformin and may lead to lactic acidosis), - nifedipine (increases effx of metformin and may lead to lactic acidosis) - iodinated radiocontrast agents (IV contrast may deteriorate the renal function, causing increased metformin exposure; metformin must be withheld before and after IV contrast agent for 48 hrs as long as renal function is normal)
plantar fasciitis clinical manifestations
- sharp heel pain that is worse w/ first step in the morning or after a period of inactivity (pain will lessen gradually with activity, but worsens toward the end of the day w/ prolonged weight bearing) -pain may worsen by walking barefoot on hard surfaces or by walking up stairs -pain may be relieved by unloading the affected foot (via sitting, elevating foot) - tenderness is best elicited by the examiner dorsiflexing the pt's toes w/ one hand in order to pull the plantar fascia taut, and then palpating w/ the finger of other hand along the fascia from the heel to the forefoot.
pt who are likely to develop Polymyalgia Rheumatica include...
- those w/ HLA-DR4 gene more likely to develop the disease, especially after an infx w/ adenovirus or parvovirus B19 -women over 50 y/o
Diuretic use vs HF
- used to relieve fluid retention but doesn't improve mortality - improve exercise tolerance - pt can be taught to adjust their diuretic dose based on changes in body weight (like sliding scale) - electrolyte deplotion a frequent complication - higher dose of diuretics are a/w increased mortality -w/ HFrEF, should never be used alone; w/ HFpEF, if BP is normal, may use alone
At what age should a child achieve complete toilet training?
-40 to 60 percent of children are completely potty trained by age of 3; however, some children won't be trained until after they are 3 ½. -if your child is over the age of 4 and fully potty trained by day, but having 3 to 5 wet incidents at night per wk, talk to your pediatrician
Urinalysis Dipstick Test
-Acidity (pH 5-8): acidic urine may indicate high protein diet, DKA, drugs, dehydration, diarrhea. Alkaline urine is found with various drugs, infx w/ certain bacteria, and acute and chronic renal failure - Protein (negative): increased protein indicates impairment of GFR apparatus, CHF, diabetes, glomerulonephritis, pyelonephritis, preeclampsia, malignant HTN. Albumin is the primary type of protein that will appear in urine, but other types can be found in states such as multiple myeloma - Glucose (negative): when serum glucose concentration rises above 180 mg, spill happens. Happens w/ DM, thyrotoxicosis, intravenous glucose administration, catecholamine surges, liver dysfunction, acute pancreatitis, asphyxia (such as w/ CO poisoning) - Ketones (negative)- reflect altered cellular metabolism when there is an inadequate supply of glucose to meet an increased metabolic demand. Ketones are byproduct of lipid breakdown. Commonly elevated in vomiting, diarrhea, malnutrition, pregnancy, hyperthyroidism. Also is part of the diagnostic cirteria for DKA - Bilirubin (negative): bilirubin is normally reduced in the intestine to be excreted in urine as urobilinogen. when present indicates liver disease. The pattern of obstructive disease includes elevated bilirubin and low urobilinogen. - Urobilinogen (0.2-1/EU/dL): urobilinogen can also be elevated in hemolytic processes, liver parenchyma damage, hepatitis, cirrhosis, pnacreatic cancer, choledocholithiasis - Blood (reference) - Nitrite (negative): product of the conversion of endogenous nitrates to nitrites and has high specificty for gram negative bacteriuria - Leukocyte esterase (negative): enzyme produced by WBC, usually in response to infx
USPSTF Colon cancer screening
-Ages 50-75 -FOBT (fecal occult blood test), FIT, or FIT-DNA annually at 50y, or at 40y if 1st degree relative -Colonoscopy q 10y -Flexible Sigmoidoscopy q 5y or every 10 years with a FIT every year. The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient's overall health and prior screening history.
Enterobius Vermicularis tx
-Albendazole 400 mg PO once on empty stomach, repeat in 2 wks -Mebendazole 100 mg PO once, repeat in 2 wks -Pyrantel pamoate 11 mg/kg, maximum 1 g (the most frequently used med in US b/c it is cheap and available OTC and has efficacy clsoe to 100 % if 2 doses are given 2 wks apart) (AE include anorexia, N/V, abdominal cramping, diarrhea, neurotoxic efx, transient increases in hepatic enzymes)
Lewy Body Dementia tx
-Cholinesterase inhibitors (donepezil, rivastigmine) = first line *pts are dopamine sensitive, levodopa (dopamine agonist) will cause hallucinations, agitations, and confusions
Pyloric stenosis tx
-Fluid and electrolyte management -Pyloromyotomy is a surgery that will relieve the constriction and allow normal passage of stomach content into duodenum.
folic acid deficiency cause
-Inadequate diet of fruits and green vegetables (MC) -Pregnancy - ETOH excess - malnutrition
Sjogren Syndrome symptoms
-Keratoconjunctivitis sicca (dry eyes) -Burning, itching eyes - blurry vision -Xerostomia (dry cotton mouth) -Difficulty swallowing unless washing food down with drink - difficulty tasting/swallowing -Enlarged parotid gland -ulceration/perforation of the septum - dryness of skin/vagina - swelling of the gland, can cause pain - infx more likely d/t dry skin symptoms start at middle age
Urinalysis range -Leukocytes -RBC -nitrites -leukocyte esterase
-Leukocyte: <= 10 WBC's/mL -RBC: <5 cells -nitrites: negative (not very specific for UTI: only 25% w/ UTI have positive nitrites) -leukocyte esterase: negative (dipstick)
Gout risk factors
-Men > Women -Women with menopause -ETOH use -Diuretic Tx or HCTZ use -obesity -family hx gout -diet: Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, -trauma -stress -IV contrast -acidosis *milk products may have a protective effect
Endometriosis risk factors
-Menarche before age 12 -Family history in first-degree relative -Menstrual cycles <28 days -Menstrual flow >7 days -Fewer than 2 full-term pregnancies "career woman's disease" (*delayed childbearing*) -Congenital abnormality
Trichomoniasis Recommended Regimen, Alternative Regimen
-Recommended Regimen: Metronidazole 2 g PO ONCE (or Tinidazole 2 g PO ONCE) -Alternative Regimen: Metronidazole 500 mg PO BID for 7 days
Intussusception dx
-Ultrasound (if US is readily available such as in ED) -Fluoroscopy (also can be nonoperative reduction) - self reduced w/ barium or enema
Ototoxic drugs
-aspirin, aminoglycosides, vancomycin, erythromycin, loop diuretics (like LASIX), the anti-malarial medications, sildenafil (tadalafil, vardenafil) and cisplatin
Multiple sclerosis dx
-diagnosis cannot be based exclusively on laboratory findings. *MRI with gadolinium is very effective for visualizing white matter lesions in the CNS.* 2nd: *Oligoclonal bands and elevated CSF IgG and IgG synthesis rates are present in 80% of MS cases*
Bisphosphonate drugs
-dronate Alendronate Risedronate Ibandronate Zoledronic acid
cryptorchidism dx
-imaging is notroutinely warranted -made clinically, having the child sit in the cross-legged position ("tailor's position") or other positions, Holding the testis that can be manipulated into the dependent portion of the scrotum in position for at least 1 min fatigues the cremasteric muscle; after this maneuver, a retractile testis remains in the scrotum whereas an ectopic testis immediately springs out of the scrotum
Nuclear stress testing
-injecting a radioactive substance into the blood, then using gamma-ray cameras to see how the blood moves through the heart -shows how well the heart is at keeping itself saturated with oxygen-rich blood.
Vaccinations that children that are immunosuppressed should not receive...
-live viral vaccines (OPV, MMR, varicella) -live bacterial vaccines (BCG) *unless the individual is in the remission stage *some live vaccines can be administered safely in some immune system disorders or when the benefit of the vaccine outweighs the side effects.
G6PD deficiency tx
-most cases are self-limited -avoid oxidative meds (ASA, dapsone, sulfonamides, nitrofurantoin) during hemolytic episode -avoid known triggers -hydration -blood transfusion
Beta agonists always end in...
-ol (e.g.Salmeterol)
Diabetes mellitus self monitoring frequency if on pill
-once a day if on pill
ICS always end in...
-one (e.g.fluticasone)
Psoriasis S/S
-papules, plaques -SILVERY scales -itching (skin folds are more itchy)
Xanax -onset -duration
-quick onset (quicker than Ativan) -4-6 hours (regular); 11 hrs (ER)
infective endocarditis treatment plan
-refer to cardiologist or ED for hospitalization and IOV abx - blood culture x 3 (within first 24 hrs) to dx IE - CBC and ESR greater than 20mm/hr
Furosemide contraindication
-sBP < 90mmHg -severe hyponatremia -acidosis
Tetracycline pt education
-take med while sitting upright at least 30 mins (possible esophagitis) -follow med w/ 8 oz water -doxycycline and minocycline- take on empty stomach -avoid unnecessary exposure to sunlight- increased risk of photosensitivity- recommend SPF at least 30 -notify primary care provider of any hepatotoxicity
Bowen's family system theory
-views the nuclear family as a part of a multigenerational extended family with patterns that repeat over generations, this is called the multigenerational transmission process -theorizes that familial emotional and interaction patterns are reflected in eight interwoven concepts, but in families, there is the differentiation of self and triangles - a change in one persons's behavior affects the others in the family
am i protected if I missed 1 OC pill anywhere in the pack or started a new pack 1 day late? What is the pt instruction?
-you're still protected against pregnancy -take the last pill you missed ASAP, even if this means taking 2 pills together in one day -carry on taking the rest of the pack as normal -take 7 day pill-free break as normal, or if on everyday (ED) pill, take dummy (inactive) pills -no need for extra contraception or emergency contraceptions
meds that can cause tinnitus
-zycam -lasix -chemo drugs -ASA in high dose -Antibiotics, including polymyxin B, erythromycin, vancomycin (Vancocin HCL, Firvanq) and neomycin
obese BMI pregnant mom: 1st trimester total wt gain
0 to 1 lb
ESR normal rate
0 to 15 mm/hr in men younger than 50 0 to 20 mm/hr in men older than 50 0 to 20 mm/hr in women younger than 50 0 to 30 mm/ur for women older than 50
rabies vaccine preexposure schedule
0, 7, 21, 28 days
when is 1st trimester?
0- 13 6/7
NIHSS stroke scale result
0- no stroke symptoms 1-4- minor stroke 5-15- moderate stroke 16-20 moderate to severe stroke 21-42- severe stroke
overweight BMI pregnant mom: 1st trimester total wt gain
0-2 lbs
TSH normal range
0.4- 4 mIU/Liter
Digoxin therapeutic range
0.5 - 2.0 ng/mL
obese BMI pregnant mom: recommended rate of wt gain in 2nd and 3rd trimester
0.5 pound/wk (0.4- 0.6)
overweight BMI pregnant mom: recommended rate of wt gain in 2nd and 3rd trimester
0.6 pound/wk (0.5-0.7)
Metformin decreases A1C by
0.9 to 1.4 %
NuvaRing is changed every __________
1 month
ASQ-3 age group
1 month through 5 1/2 years old
normal BMI pregnant mom: recommended rate of wt gain in 2nd and 3rd trimester
1 pound/wk (0.8-1)
benefits of allergy shot are seen within
1 to 2 yrs
birth control patch is changed every
1 wk
depo provera: can take up to __________ to have normal periods
1 yr
Basophil: role
1% of WBC -key allergy response: release histamine and other mediators of inflammation (eg asthma) -contain heparin
Ankle Brachial Index Score Index
1- 1.4 :normal <1: abnormal <= 0.5: severe PAD
underweight BMI pregnant mom: 2nd and 3rd trimester rate of wt gain
1-2 lb / wk
infant gynocomestia lasts typically...
1-2 mths
Hand foot mouth disease rash duration
1-2 wks
Hep A schedule
1-2 years old (2 doses--6 months apart)
subacute sinusitis lasts
1-3 mths
Ankle Sprain Grade I recovery time
1-3 wks
Eosinophil: role
1-5% of WBC - some allergy response - parasite infx
Ativan dosage
1-6 mg/day in divided doses *0.5 mg available, you can ask pt to take half of that twice a day duration: 8 hrs *Half life: 10- 20 hours *short-term only: should be taken off every 4-6 weeks *longer than 4 weeks, start to see withdrawal and will cause more anxiety and more sleep issues
ADHD screening tools for peds
1. ADHD Rating Scale IV 2. ADHD Rating Scale V 3. Vanderbilt (6-12, but can be used >=4) 4. Conners Comprehensive Behavior Rating Scales (6-18, teens) 5. Child Behavior Checklist (6-18)
JUST NOTE: 12 most common PEDS ICD-10 Codes:
1. Abdominal Pain 2. Acute bronchitis 3. Acute pharyngitis 4. Allergic inflammation of the nasal airways 5. Asthma 6. Chest pain 7. Diabetes Mellitus 8. Headache 9. Otitis Media 10. Pain in limb 11. Routine child health examination 12. UTI
Alpha Glucosidase inhibitor list (2)
1. Acarbose (Precose) 2. Miglitol (Glyset)
Myasthenia Gravis workup
1. Antibody titer for acetylcholine receptor (assay for the binding antibody is the most sensitive) -In those with purely ocular myasthenia, the sensitivity of AChR-Ab testing is considerably lower, detectable in approximately half of patients 2. MuSK antibody titer * about 6-12 % of pts will have negative antibody titers fo both titers 3. cholinesterase inhibiting drug test: improvement in strength after injection of edrophonium (Tensilon) 4. repetitive muscle stimulation teest (decremental response) 5. single-fiber EMG and/or repetitive stimulation (RNS) studies are diagnostic
Which meds should be stopped before EEG?
1. Anticonvulsants 2. Antidepressants 3. Stimulants 4. Alcohol
Concussion PE
1. Appearance- careful inspection of general appearance 2. head and neck- palpating the head and neck is important when looking for associated skull or cervical injury 3. facial bones- palpate the facial bones and the periorbital, mandibular, and maxillary areas after any head trauma 4. Jaws: open/close the mouth to help the evaluation of possible TMJ pain, malocclusion, or mandibular fracture 5. Nose: inspect the nose for deformity and tenderness, which may indicate a possible nasal fracture 6. Presence of discharge: persistent rhinorrhea or otorrhea (clear) indicates a possible associated skull fracture 7. Vision: perform a careful, detailed neurologic exam that includes eval of the visual fields, extraocular movements, pupillary reflexes, and level of the eyes 8. Strength and sensation: assess upper-extremity and lower- extremity strength and sensation 9. coordination and balance- concussed pts often have difficulty w/ finger-nose-finger test and will use slow, purposeful movements to complete the task.
afib tx - rate control meds
1. BB - atenolol 25-100 mg/day PO - carvedilol 6.25 mg/day PO - esmolol 0.5 /kg bolus IV followed by 0.05-0.2 mg/kg/min (not used in PCP b/c it is intravenous) - metoprolol- 2.5- 5 mg q 5 mins IV (max 15 mg per total dose; not used in PCP b/c it is intravenous); for chronic therapy: 50-200 mg/day PO *generally, atenolol, carvedilol used in PCP setting 2. Nondihydropyradine CCB - Verapamil - Diltiazem 3. Digoxin *rhythm control is usually performed by the cardiologist
afib PE
1. BP (postural changes (orthostatic hypotension), widened pulse pressure) 2. count apical rate vs radial pulse (afib may causes an apex-radial pulse deficit, because each ventricular contraction may not be sufficiently strong to transmit an arterial pulse wave through the peripheral artery) 3. s/s hyperthyrodisim to help rule it out (exophthalmos, goiter, tremor) 4. check neck vessels, carotid upstroke, jugular vein distension, cannon waves) 5. additional heart sounds, clicks, murmurs (especially mitral stenosis, mitral regurgitation), third heart sound; 4th heart sound will not be heard in afib as it is related to atrial contraction 6. lungs may reveal evidence of primary lung disease, pneumonia, or heart failure 7. leg edema may indicate HF 8. neuro exam for secondary stroke
Interstitial Cystitis management
1. Behavioral Modification - restrict fluid - progressive timed voiding on 2-3 hr schedule - avoid kegel exercise - tx comorbid infx or depression 2. Pharm - Elmiron 100 mg TID (treats pain and discomfort of IC) - Elavil at low dose (SE: dry mouth, wt gain, sleepiness) - Nifedipine and other CCB's 3. procedures - cystourethrectomy - bladder instillation w/ DMSO, heparin, or lidocaine
Infectious Mononucleosis lab work
1. CBC w/ diff- should do - lymphocytosis noted (defined as absolute count > 4500/microL) - WBC 12,000- 18,000 /microL, may be higher 2. Monospot- should do - also called heterophile antibody testing - not highly sensitive/specific (less sensitive in young children) -will be negative usually in the 1st wk of the infection -will be also negative when infx goes away -UTD: Further testing for specific antibodies to EBV is not necessary for patients with a reactive heterophile antibody. 3. EBV specific antibodies - this measurement is usually unnecessary since the vast majority of pts are heterophile positive - VCA IgM and IgG (viral capsid antigen)- IgM want approx 3 mths later; IgG persist for life (do this to make sure pt has mono) - Anti-EBNA (nuclear antigen) antibody- appears 6-12 wks after onset and persist throughout life *Positive VCA IgM and negative Anti-EBNA usually makes diagnosis almost certain
Rheumatoid Arthritis diagnostic works
1. CBC w/ differential 2. ESR/ CRP 3. RF + Anti-CCP antibodies 4. If RF ANA or Anti-CCP positive, perform ANA and Anti-smith (these have high specificity for SLE 5. Creatinine 6. LFT 7. UA 8. serum uric acid (gout) 9. radiograph of the hands, wrists, feet: obtain during he initial eval primarily as baseline for monitoring disease progression; however, characteristic joint erosions may be observed in pts presenting w/ symptoms for the first time, and hence aid in dx; additionally, in pts w/ other disorders, such as psoriatic arthritis, gout, or spondyloarthropathy, radiographic changes more characteristic of these conditions may point to na alternative dx -serologic studies for infx- in pts w/ very short hx, particularly those who are serongative for anti-ccp and RF, we perform serologic testing for human parvovirus B19, HBV, HCV; in areas endemic for Lyme, perform studies for Borrelia -MRI and US: do not have an established role in routine eval of pts w/ polyarthritis
Entresto contraindications
1. CKD (cre > 2 be careful) 2. cannot be used concurrently w/ ACE or ARB- ACE must be stopped for 36 hrs before first dose of Entresto 3. hx angioedema 4. Class IV HF
Fibromyalgia workup
1. CRITICAL: obtaining an in-depth Hx and PE reduces the need for extensive and expensive objective tests 2. CBC (anemia) 3. ESR (inflammatory/rheumatological) 4. CRP (inflammatory) f 5. Vit D (deficiency associated w/ fibromyalgia) 6. TSH 7. ANA 8. Rheumatoid Factor 9. Sleep studies (sleep disturbances)
hyperuricemia has correlation to what disorders
1. CV conditions 2. CKD 3. metabolic disorders
SGLT2 inhibitor list (3)
1. Canagliflozin (Invokana) 2. Dapagliflozin (Farxiga) 3. Empagliflozin (Jardiance) - Independent of glycemic control, if established or high ASCVD risk and/or CKD, recommend SGLT2i and/or LA GLP-1 RA
1st gen cephalosporin and available route of administration
1. Cephalexin (Keflex)- PO 2. Cefazolin (Ancef)- IV/IM
Diaper rash prevention
1. Change absorbable diapers frequently. 2. Wipe well with unscented wipes 3. Leave off the diaper to let the skin air dry 4. barrier ointment like Zinc oxide (A+D Ointment, Desitin, Diaparene), Petroleum JKelly (Vaseline, Aquaphor) after bathing or washing to decrease ambient mositure in diaper
First Generation Antipsychotic list
1. Chlorpromazine (Thorazine) 2. Fluphenazine (Prolixine) 3. Haloperidol (Haldol)
histamin 2 blockers list (3) <H2 blocker>
1. Cimetidine (Tagamet) 2. Famotidine (Dyspep, Pepcid) 3. Ranitidine (Zantac)
traveler's diarrhea pretravel abx Rx
1. Cipro 500 mg BID x 3 days 2. Azithromycin 500 mg daily x 3 days *abx can be discontinued when pt feels better
SSRI approved by FDA to tx depression (5)
1. Citalopram (Celexa) 2. Escitalopram (Lexapro) 3. Fluoxetine (Prozac) 4. Paroxetine (Paxil, Pexeva) 5. Sertraline (Zoloft)
Second Generation Antipsychotic list
1. Cloazpine (Clozaril) 2. Risperidone (Risperdal) 3. Olanzapine (Zyprexa) 4. Quetiapine (Seroquel) 5. Ziprasidone (Geodon) 6. Aripiprazole (Abilify)
Atypical antipsychotic list
1. Clozapine (Clozaril) 2. Risperidone (Risperdal) 3. Olanzapine (Zyprexa) 4. Quetiapine (Seroquel) 5. Ziprasidone (Geodon) 6. Aripiprazole (Abilify) 7. Olanzapine/fluoxetine (Symbyax)
Ganglion cyst tx
1. Conservative tx w/ NSAIDs and physical therapy IF neurovascular symptoms are not present - most adults heal within 6 mths w/ conservative tx (OVER 50% OF GANGLION CYST DISAPPEAR SPONTANEOUSLY) 2. Aspiration: may be necessary if the mass continues to bother her over time or grows in size 3. Excision: is used if the pt complains of neurological sxs and if other techniques have not improved her sxs and gotten rid of the masses *** Can reoccur - 50% chance w/ aspiration - 10% chance w/ excision