NR661 Boards Review

Syphilis screening

Nontreponemal tests (VDRL = venereal dz research lab; RPR = rapid plasma reagin; TRUST = toluidine red unheated serum test).
Treponemal tests: used to confirm nontreponemal tests, reported as reactive or nonreactive, quantitative.

Thyroid testing

If TSH high: get repeat + free T4
If repeat TSH high/free T4 low: primary hypothyroidism (start levothyroxine, recheck in 6w, then annually once euthyroid)
If repeat TSH high/free T4 normal: subclinical hypothyroidism (no replacement until TSH >10).

Warfarin Management

Therapeutic INR range: 2-3 for most people w/chronic afib.
INR <5 w/out bleeding: stop warfarin temporarily, recheck INR next day, decrease dose when INR is closer to therapeutic range.
Pt at high risk for bleeding, is bleeding, or INR >4: vit K.
High ris

WBCs in stool

Indicates inflammation or infection.
Pt s/s infectious etiology? Consider bacterial/viral infections.
Pt w/out s/s infection? Consider Crohn's or UC.

Geriatric pneumonia tx

S. pneumo most likely (age extremes).
Consider consequences of potential tx failure.
Rx: resp quinolone (monitor for long QT in geri pt's on quinolones)

Cauda equina syndrome

Medical emergency!
S/s: urinary retention w/overflow incontinence, saddle anesthesia, sciatica (BLE), leg weakness (antalgic gait).

Parkinson's

Pill-rolling tremor = early s/s, occurs at rest, worse w/emotional stress, better/ceases w/sleep

Meds to use cautiously/not at all in asthma

Beta blockers (can precipitate bronchoconstriction; ophthalmic can exert systemic effects).

Do renal stones typically present w/fever?

No

Are OTC preg tests accurate?

Yes
High sensitivity/specificity
+ UPT will correlate w/serum (hCG)

Acute bacterial prostatitis

Prostate tender (esp. w/BMs)
Common cause <35yo: STD (gon/chla).
Screen for STDs (if -, urinary pathogen is likely)
If PSA up at dx: elective recheck in 4w

CN II

Optic nerve
Responsible for vision
Snellen chart

Geri pneumococcal vax recommendations

At 65yo: give x1 no matter what.
If given before 65yo and 5yrs has lapsed: give one now, then other in 1yr
Two vax available: PCV13 & PPSV23
Routine revax not recommended.

Flu dx

Based on nasal swab results

Abuse in preg

Tends to occur throughout preg
Preg women more likely to be abused than non-preg.
When women abused before preg, abuse generally escalates during.
Abuse not specific to certain trimester.

Breast lump evaluation

Initial: H&P critical (location of lump, how/when first noticed, any nipple discharge, any changes in sizes esp. r/t menses, family hx).

Cause PSA increase

DRE: clinically insignificant (about 0.26-0.4 x48-72h)
Prostate Bx: increases about 8 x4wks after bx
Prostate infection/ejaculation: significant increases in varying amounts

Lumbar strain pt education

Some pain expected, won't cause permanent injury
Gradually engage in ADLs, normal walking as tol.
Will speed up return to normal act.
No bedrest (pts feel better sooner, fewer complications when avoided).

Plantar fasciitis

Inflammation of ligaments in plantar fascia (thick white tissue that starts at heel, runs under foot to toes, supports foot when walking).
Pts at higher risk: long-distance runners, dancers, people on their feet for long time.
Dx: based on PE (no imaging)

Anemia of chronic dz

Usually normocytic/chromic (30% microcytic).

Lower extrem. edema

Common in preg.
Monitor for pre-eclampsia, HF, etc.
Tx: rest/elevation of legs
No longer considered criterion for pre-eclampsia.

Mono

Kissing dz"
Epstein Barr virus
"3 F's and an L": Fever, PHaryngitis, Fatigue, Lymphadenopathy
Lymphocytosis (incr. number of circulating lymphocytes, usually predominant WBC in viral infections, esp. mono; lymphocytes usually decreased in bact. infection

Sildenafil (Viagra) significant SE

Decreased BP, esp. if antihypertensive also taken.
Only prescribe if pt has stable BP.
Specific drug-to-drug interaction w/alpha blockers ("-osin")

SSRI SE's

Wt gain (w/in 6mo of tx)
Decr. libido (w/in several wks)
Jitteriness/restlessness (usually subside after 1mo or less)

Cohort study

Observational
Prospective
"What will happen if...?

Case control study

Looks backward in time (retrospective)
"What happened when...?

Controlled trial

Experimental study

Aortic regurg

Long asymptomatic period, then exercise intolerance, then dyspnea at rest.
Left ventricle eventually fails unless valve replaced.

Randomized controlled trials

The epitome of all research designs.
Provides strongest evidence for concluding causation.
Subjects randomly assigned to tx groups.
Experimental.

Anomia

Difficulty naming familiar objects.
Example of mild impairment.

Significance of lower extr. edema in preg.

Common
Monitor to make sure other more serious conditions aren't occurring (pre-eclampsia, HF, etc.).
Best tx: rest, leg elevation.
No longer a criterion for pre-eclampsia.

Iron replacement

Better absorbed on empty stomach, but poorly tolerated, so eat w/food rich in vit C (enhances iron absorption).

Direct inguinal hernia

Seen in Hesselbach's triangle (boundaries: inguinal ligament, rectum abdominis muscle, epigastric vein & artery).
Weakness in inguinal canal floor causes protrusion of direct inguinal hernia (usually result of connective tissues abnormalities, but can be

Pernicious anemia

B12 deficiency anemia
Glossitis (inflammation, color change, pale, bright red, swollen); not seen in all pernicious anemia pt's; should prompt you to check B12/folate.

Most common reason geri get PUD

H. pylori

Second most common reason geri get PUD

NSAIDs

Time frame for distinguishing between depressed mood & clinical depression

2w
Typical screening questions ask "In the past 2w, have you felt....

Most common characteristics in Alzheimer's

Memory impairment
Visual-spatial disturb.
Indifference
Occasional delusions
Agitation

Tx for gonorrhea in preg

Tx for chlamydia & gonorrhea (usually found concurrently).
No teratogenicity if standard tx used.
Rescreen later in preg. regardless of s/s.

Action taken if pt unable to make informed decision d/t mental incapacity, but does have DPA

DPA should make decision based on pt's known values

Split murmur

Created because of valve closure (S2 created by closure of aortic & pulmonic valves).
Normally split w/inspiration, almost never w/expiration.
Should never be fixed (indicates pathology such as atrial septal defect, pulmonic stenosis, MR).
Get echo w/fixe

What is your first responsibility if colleague takes pt's extra meds?

Report them to state board of nursing

Varicocele pain relieved by:

Recumbency because lying down relieves dilation of spermatic veins.
Pain more noticeable w/standing.
Scrotal supporter may give some relief.

What factors contribute to vit D deficiencies in geri?

Inadequate intake.
Impaired synthesis of previtamin D.
Lack of sun exposure.
As renal status declines, hydroxylation diminishes, diminishing available vit D.
Dark skin = increased risk of deficiency.

Anosmia

Inability to smell.
CN I assessed (olfactory); lesions can occur.
When assessing use familiar smell and ask pt to ID.

Sleep disturbance a/w anxiety

Difficulty falling asleep

Sleep disturbance a/w depression

Early morning awakening
Difficulty remaining asleep

Sleep disturbance a/w mania

Never feels tired enough to sleep

When does a full-term newborn dx'd with hyperbilirubinemia have peak in bili level?

3-4d
Dx'd when level >5

When does premi's bili level peak when dx'd with hyperbilirubinemia?

5-7d

Why does amlodipine cause urinary incontinence?

Long-acting CCB.
Calcium responsible for muscle contraction, so CCB can sometimes impair detrusor contraction.
If occurs: try lowering dose, try different class, or (last resort) use incontinence products.

Common causes of afib

Hyperthyroidism (most common presentation in 60yo and older = afib).
Imbalance in serum lytes (K, Na, Ca, Mg): involved in conduction of electrical impulses in heart, have potential provoke cardiac arrhyth.
Chron. kidn. dz

Strategy for minimizing incidence of SE's of SSRI in geri

Take at bedtime
Start low and go slow

What do you do if pt's BGL consistently elevated before PM meal, already on 22u NPH in AM?

Indicates need for more AM NPH (intermediate-acting).
Increase by 2-3u at a time.
Check BGL before dinner x3d after dose increase; if not at goal, increase again.

Papilledema

Swelling of optic nerve head & disc.
Secondary to increased ICP
Cardinal symptom of increase ICP = HA; papilledema = secondary finding.

CN VIII

Vestibulocochlear
Responsible for hearing
Assess each ear individually.
Weber/Rinne to distinguish between conductive and sensorineural loss.

Is a family h/o migraines an absolute contraindication to oral contraceptives?

No.

What is the 3 most common cause of cancer deaths in men?

1. Lung cancer
2. Prostate cancer
3. Colon cancer

What type of RBCs will be present in folate-deficiency anemia?

Macrocytic, normochromic

What will the ESR level be in temporal arteriritis?

Elevated, can be used to diagnose

S/s of RA

Symmetrical joint stiffness, swelling, pain.
Hands, wrists, elbows, ankles, shoulders.
Fatigue, malaise, fever, generalized body aches.

When can an infant be given whole milk?

12mo

What is a common med for acute gout flareup?

Indomethacin (Indocin)
NSAIDs (naproxen Na) BID
Colchicine can be added if no relief w/NSAIDs.

What is used for maintenance of gout?

Allopurinol and/or probenecide.

What are some complications of untx'd gout?

Loss of joint mobility and renal failure.
High urate levels can lead to renal stones as well.

Is endocarditis prophylaxis necessary in MVP?

No

Bouchard's node

Bony nodules at PIP of hands.

Heberden's nodes

Nodules on DIP on hands.
OA

Tophi deposits

High levels of uric acid in blood, cause nodules in joints that can eventually destroy the bone.

DM is 2-3x higher in.....

Mexican Americans versus non-Hispanic

If all cholesterol levels are abnormal w/TGL being >500, what should be done?

Initiate nicotinic acid (Niacin, Niaspan) for tx of high TGL >500 and high cholesterol.
Lifestyle modifications as well.

What is Cullen's sign?

Indicates possible pancreatitis.
Yellow-blue skin color around umbilicus.
Maybe d/t pancreatic enzymes in the ligament and sq tissues around umbilicus.

What is gold standard for dx'ing H. Pylori?

Endoscopy w/tissue bx.

At 6mo, what food should be started first?

Fe-fortified rice cereal.
Introduce only 1 food at a time.

What are 3 screening tests that can be used in initial screening for DM?

Fasting BGL >126 x2
Random BGL >200 x2
OGTT 2h >200
A1C >6% x2
Any one of these can be confirmed with a different one.

What is a bullae?

Superficial vesicle filled w/serous fluid >2cm.

If mom tests + for HBsAg, what should we do for the infant?

Give hep B vax and immunoglobulin

What's the confirmatory test for HIV?

Western blot

Findings consistent w/syphilis (Treponema pallidum)

Maculopapular rash palms/soles
Lymphadenopathy
Condyloma lata

What is condulo accuminata?

Genital warts
Caused by HPV
Spreads to other by skin-to-skin

What oral contraceptive is NOT ok to prescribe for breastfeeding mothers?

Low-dose w/at least 20mcg of estradiol

Mom brings in 16 day old w/rash on eyebrows. First noticed yesterday, worse today. Son doesn't seem bothered by it. Baby was full-term vaginal, 7lbs 4oz, obs for 48h after delivery d/t inadequately treated GBS, d/c'd home w/out concern. Exclusively formul

No tx: rash is seborrheic derm (AKA cradle cap in infants, dandruff in adolescents)

42yo male w/hyperlipid, HTN, T2DM c/o chronic fatigue x1yr, unrelated to sleep/exercise. Also c/o constipation, dry/cold skin. Denies SI, guilt, psychomotor probs, other mental health issues. Meds: atorvastatin, metformin, amlodipine. VS: 98.3F, HR 80, RR

Hypothyroidism

Baby born at 36w gest, tested + for galactose 1-phosphate uridyltransferase deficiency on newborn screen. Can mom breastfeed?

NO!
Galactosemia = typically autosomal recessive dz where there's deficiency in galactose-1-phosphate uridyltransferase. Without this, when galactose is consumed, levels of plasma galactose and erythrocyte galactose-1-phosphate are elevated, leading to gl

When would you give hepatitis B vaccine and hepatitis B immunoglobulin?

Vax is given for long-term prophylaxis to prevent hep B infection.
Immunoglobulin is given to prevent hep B infection when person has been directly exposed to hep B. Not a vax, doesn't protect against long-term prophylaxis.

What is the caloric content of infant formula and breast milk?

20 kcal/30mL

Which hep viruses are associated with hepatocellular cancer?

B and C

Where is the murmur a/w AS auscultated?

Harsh, high-pitched in R 2nd ICS.
Typically radiates to carotid arteries and apex.

When is a thrill palpated?

Grade IV

What is podagra?

Pain in joint of great toe d/t to accumulation of uric acid/salts in joint d/t gout.

Why does hypovolemic shock occur in pelvic fx?

Secondary to internal bleeding from fx'd bone fragment that lacerates artery or vein. Pelvis can accommodate large amount of fluid.

Lead poisoning

Causes microcytic anemia by mimicking healthful minerals (calcium, FE, zinc).
S/s: abd pain, constipation, vom, blue-black line on gums.
Absorbed by bones --> interferes w/RBC production and calcium absorption needed to keep bones healthy.

Molluscum contagiosum

Can occur in genitals.
Viral infection that causes smooth, round, tiny papules, 5mm or less, central umbilication w/white plug.

Complications of PID

Higher risk of ectopic preg.
Fallopian tube scarring
Infertility d/t scarring/trauma from inflammation.

Which PO birth control is contraindicated in breastfeeding?

low-dose BC w/at least 20mcg of estradiol (Alesse, Lo-estrin).

Vesicular breath sounds

Heard best over base of lungs
Soft and/or blowing
Heard throughout inspiration, fade w/expiration

Bronchial sounds

Heard over bronchi (largest tubes in ant. chest).
Loud, high-pitched

Tracheal sounds

Heard over trachea
Harsh, similar to air blown through pipe

Consolidation on XR

Bacterial pna
Not present: bronchitis, COPD, atypical pna

RhoGAM's MOA

Given to moms w/Rh-neg blood when fetus has Rh-pos blood.
Rho-GAM protects mom from developing antibodies by destroying Rh-pos fetal RBCs in mom's blood system.

T2DM pt w/normal UA except for epithelial cells. What's next?

Order 24h urine for microalbumin
Epith cells are present inside lining of organs. Few = normal, but with h/o T2DM, kidney function must be assessed through 24h urine for microalbumin.

Who should be screened for thyroid dz?

Women 50yo and older

Kernig's maneuver

Have pt flex both hips/legs, then straighten legs against resistance.
Tests for meningitis.
Flexion of hip/knees = + for menin.

Brudzinski's maneuver

Place pt's hands behind head, gently tuck chin to chest

Murphy's sign

Have pt inspire w/tips of your fingers on RUQ at liver border under ribs.
Pain on inspiration = possible cholecystitis

Homan's sign

Flexion of foot causing pain in posterior calf area
Suggests DVT

Best screening test for hypothyroidism and hyperthyroidism

TSH (if abnormal, further tests should be done)

Infant should be back to birth wt by:

2w of age

Infant should be nursing:

Every 2-4h

Number of wet diapers for newborn:

6-10 diapers/day (24h)

Bullous impetigo

Skin infection
Commonly seen on face/hands
Yellow, honey-colored fluid blisters w/drainage that turn into scabbed lesions that continue to spread until tx

Diagnosing Hashimoto's

Thorough hx
PE
1 or more labs: TSH, anti-thyroid antibodies, free T4

Auspitz sign

Pinpoint bleeding from psoriasis where skin is scraped

Moderate persistent asthma

FEV 60-80%

Intermittent asthma

Normal FEV between exacerbations
FEV >80%

Mild persistent asthma

FEV >80%

Severe persistent asthma

FEV <60%

Mom has tenderness, soreness of nipples in first 2w of breastfeeding. Advice?

Normal during first couple of weeks, will eventually go away.
Continue to breastfeed.
Make sure infant is latching properly.

Bell's palsy

Affects CN VII: affects ability to smile, close eye on affected side, drooping/drooling on affected side. Sometimes causes smoothing of forehead on affected side.
Tx: Steroids (prednisone w/in 72h, reduces risk of permanent paralysis) + antiviral (b/c lik

Method to assess corneal abrasion

Fluorescein stain: eye stain used to detect abrasions/FB in cornea.

Myxedema

Rare, sometimes fatal
Severe Hypothyroidism
s/s (low BP, decreased breathing, decreased body temp, unresponsiveness, coma).

Acute sinusitis s/s

HA
Facial pain worse w/bending over
Eye/ear pressure/pain
Aching in upper jaw/teeth
Reduced smell/taste
Cough (esp at night d/t nasal drainage)
Sore throat
Bad breath
Fatigue

Macular degeneration

Slow or sudden painless loss of central vision

Plan for exercise-induced asthma

Premedicate 20min before starting exercise.
Best controlled by Proventil inhaler (bronchodilator)
Prevents vasospasm of bronchioles and SOB w/exercise
Bronchodilators usually last approx. 4h
Work quickly to open up bronchioles if acute attack/SOB occurs

Who regulates role of nurse practitioner?

Each state's laws established by Board of Nursing

S/S of acute exacerbation of asthma

Breathlessness
Cough
Wheezing
Chest tightness
Agitation
Increased resp rate
Increased HR
Decreased lung function

Most common cause of LVH

Chronic HTN

Scotch tape test

Apply scotch tape on anal area in AM (worms usually come out at night, will stick to tape)
Used to diagnose enterobiasis infection (pinworms that infect intestines).
S/S: itching around anus (usually worse at night).

Monitor in Native Americans on ACEi:

Serum creatinine and K
Native Americans have much higher rate of kidney dz/renal failure compared to other races.
Native Americans have 1 in 3 incidence of HTN.

Mini Mental Status Exam used to:

assess for cognitive impairment

Anergy

Immune system unable to perform healthy, normal response when body challenged with particular antigen.

Bronchiolitis

S/s: prominent dry, non-productive cough; later coughing up phlegm; fever (give antipyretics); inspiratory/expiratory wheezing (characteristic symptom); clear drainage
Viral caused by RSV in kids (no abx!)
Winter/spring months in infants/young kids.
No br

Croup

Viral infection
"Barking" cough
Maybe runny nose
No fever

FB swallowed by kid

Choking
Wheezing
SOB
No fever/drainage

How do you find pulse deficit?

Count apical and radial pulses at same time, then subtract to find difference between the two

Anemia in preg

Microcytic, hypochromic d/t dilutional effect of increased blood volume during preg.

Common labs seen on cert exams

Hgb
Hct
MCV
WBC
Neutrophil %
TSH
PSA
UA
(Know significance of abnormals and follow-up tests needed to eval further)

Bacterial vaginosis

Alkaline pH (only vag condition w/this)
Not considered STD (caused by imbalance of vag bacteria, sex partner doesn't need tx).
It is vaginosis, not "itis"
Does not cause inflammation (vulvovagina won't be red/irritated).
Microscopy: very few WBC, large nu

Candida vaginitis

Classified as yeast
Discharge: white, thick, curd-like, frequently causes redness/itching in vulvovagina d/t inflammation
Microscopy: large number of WBC, pseudohyphae, spores ("spaghetti and meatballs")
Candida yeast is normal flora of GI and some women'

Trichomonas

AKA trichomoniasis
Discharge: copious, bubbly, green, causes a lot of inflammation causing itching/redness
STD (partner needs tx)
Microscopy: protozoa or unicellular flagellated organism, gold standard for dx

Pharmacology study tips for cert exam

Don't memorize specific doses
Know drug's safety issues (contraindications, major drug/food interactions, well-known SE)
Know drug's indications, duration of tx.
Know first-lines and alternative
Memorize drug class and some representative drugs.
Know preg

First line med for uncomplicated CAP

Macrolide

Common SE of ACEi

Dry cough (usually shows up within 2w of starting ACEi)
Angioedema (rare, but life-threatening)
Hyperkalemia

Common CCB SE

Swollen ankles not r/t HF
HA
Urinary incontinence (impairs detrusor contraction)
(calcium responsible for muscle contraction)

Common SE of thiazides

Hyperuricemia
Hyperglycemia
Hypertriglyceridemia

Common SE of BB

Increased fatigue/depression

Most common cause of cancer death overall

Lung

Most common cancer overall

Skin

Most common skin cancer

Basal cell

Most common cancer in females

Breast

Most common cancer in males

Prostate

Cancer causing most deaths overall for males and females

Lung

Dz causing most deaths overall

Heart dz

Most common cause of death for adolescents

MVC

Skin cancer w/highest mortality

Melanoma

Most common gyno cancer

Uterine/endometrial

Second most common gyno cancer

Ovarian

Common benign physiologic variants seen on cert exams

Geographic tongue
Torus palatinus
Split/fishtail uvula

What is torus palatinus?

Chronic boney growth located midline in hard palate.
Covered w/normal oral skin.
Painless, doesn't interfere w/function.

What is a geographic tongue?

Multiple fissures, irregular smoother areas on its surface that makes it look like map.
Maybe soreness on tongue after eating/drinking acidic/hot foods.

What is leukoplakia?

Slow-growing white plaque that has firm to hard surface slightly raised on tongue or inside mouth.
Precancerous
Due to chronic irritation of skin
Causes: poorly fitting dentures, chewing/other types of tobacco.
Refer for bx because can sometimes become ma

What is oral hairy leukoplakia?

Painless white patch on tongue, appears corrugated
Located on lateral aspects
Associated w/HIV and AIDs
Caused by EBV infection of tongue.
Not precancerous

Baseline mammo

Start at 50yo
Get every 2y until 75yo
If risk factors: maybe screen earlier

What is routine screening for ovarian cancer?

No recommendation for routine screening

What is routine screening for lung cancer?

No recommendation for routine screening

Older woman c/o vague abd/pelvic pain (stomach bloating, low back ache, constipation), found to have palpable ovary on bimanual. What do you do?

Rule out ovarian cancer

What is initial workup for ovarian cancer?

Intravag ultrasound and CA 125

What are risk factors for ovarian cancer?

Early menarche
Late menopause
Nulliparity
Endometriosis
PCOS
Family h/o ovarian cancer
BRCA 1/2 mutations

What is screening recommendations for cervical cancer?

Baseline at 21yo, then every 3y until 65yo.

What is screening recommendation for prostate cancer?

No recommendation

What is screening recommendation for testicular cancer?

No recommendation

What is screening recommendation for colon cancer?

50-75yo
Either: yearly (high-sensitivity fecal occult blood test), every 5y (sigmoidoscopy), or 10y (colonoscopy)

What is recommendation for AAA screening?

One-time abd U/S: men 65-75yo smokers

If pt is fully symptomatic and is requesting refill of meds:

Give refill

Tx for Barrett's

High-dose PPIs for lifetime

Female Tanner Stages

I: prepubertal (typical 8yo)
II: Breast buds
III: Breast growth (nipples/areola one mound, no separation)
IV: Nipples/areola elevate from breast (secondary mound)
V: Adult

Male Tanner Stages

I: prepubertal (typical 8yo)
II: Testes/scrotum enlarge (scrotal skin darker/more ruggae)
III: Penis longer, testes/scrotum continues to grow.
IV: Penis wider, length continues (testes larger, darker scrotal skin/more ruggae)
V: Adult

BMI 25-29.9

Overweight

BMI 30 or higher

Obese

High tyramine foods can cause:

Dangerous food-drug interactions w/MAOI inhibitors (Marplan, Nardil, Parnate)

Caffeine and ephedra should be avoided in:

HTN
Arrhythmias
High risk for MI
Thyroid dz

Gluten

Avoid with celiac dz/sprue
Wheat (incl. spelt, kamut)
Rye
Barley
Oats (bread, cereal, pasta, cookies, cake)

Gluten free

Safe carbs:
Corn
Rice
Potatoes
Quinoa
Tapioca
Soybeans

Plant sterols, sterols

Reduce cholesterol, LDL, TGL
Benecol spread
Wheat germ
Sesame oil
Corn oil
Peanuts

Monunsaturated fats/fatty acids

Decrease risk of heart dz
Olive oil
Canola oil
Some nuts (almonds, walnuts)
Sunflower oil/seeds
Mediterranean diet

Saturated fats, trans fats

Increases risk of heart dz
Lard
Beef fat (fatty steak)
Deep-fried fast foods

Omega-3 or fish oils

Decrease risk of heart dz
Fatty cold-water marine fish (salmon)
Fish oils
Flaxseed oil
Krill oil

Magnesium

Decreases BP, dilates blood vessels
Some nuts (almonds, peanuts, cashews)
Some beans
Whole wheat
Laxatives
Antacids
Milk of mag

Potassium

Helps decrease BP
Most fruits (esp. apricot, banana, orange, prune juice)
Some veggies

Folate

Decreases homocysteine levels/fetal neural tube defects
Breakfast cereals fortified w/folate
Green leafy veggies (spinach)
Liver

Iron

Treats iron-def. anemia
Beef
Liver
Black beans
Black-eyed peas

Vitamin K

Control intake if on anticoag
Green leafy veggies (kale, collard greens, spinach)
Broccoli
Cabbage

High sodium

Increases water retention, can increase BP
Cold cuts
Pickles
Preserved foods
Canned foods
Hot dogs
Chips

Calcium

Helps w/osteopenia/porosis, helps decrease BP
Low-fat dairy
Low-fat milk
Low-fat yogurt
Cheese

Celiac dz

Lifetime avoidance of gluten
Gluten-free: rice, corn, potatoes, peanuts, soy, beans, meat, dairy, all fruits/veggies

Foods associated w/HTN

Maintain adequate intake of calcium, mag, K
Calcium: low-fat dairy/yogurt/cheese
Mg: wheat bread, nuts (almonds, peanuts, cashews), some beans.
K: most fruits (apricot, banana, oranges, cantaloupes, raisins), green veg.
Avoid high-sodium foods: cold cuts,

Foods a/w migraines, MAOI interactions

High-tyramine foods: aged cheese/meat, red wine, fava beans, draft beer, fermented foods

Food a/w anticoags

Avoid/limit high intake of vit K: green leafy veg (kale/collard greens, spinach, cabbage), broccoli.
Vit K decreases effectiveness of warfarin.

Emergencies of CV system

AMI
CHF
DVT
AAA

Emergencies of integ. system

Angioedema/anaphylaxis
Stevens-Johnson
Meningococcemia
Rocky Mt spotted fever
Lyme

Emergencies of GI system

Acute abd (surgical abd)
Acute appy
Acute pancreatitis

Emergencies of men's health

Testicular torsion
Priapism

Emergencies of psychosocial mental health

Depression w/suicidal plan
Acute mania w/psychosis
Severe anorexia

Emergencies of nervous system

CVA
Temporal arteritis HA
Subarachnoid bleeding HA

Emergencies of HEENT

Sudden vision loss/rapid worsening
Herpes keratitis
Temporal arteritis
Acute angle-closure glaucoma

Emergencies of pulmonary system

Anaphylaxis
Severe asthmatic exacerbation (impending respiratory failure)
Pulm emboli

Emergencies of renal system

Acute pyelo

Women's health emergencies

Dominant breast mass attached to surrounding tissue
Ruptured tubal ectopic preg

Anaphylaxis tx in primary care

Epi 1:1000 IM stat
Call 911
May repeat dose in 5min if necessary

Anaphylaxis is classified as:

Type I IgE-dependent reaction

Most common triggers for anaphylaxis in kids

Foods

Most common triggers for anaphylaxis for adults

Meds and insect bites

Signs to watch for in LOC changes

Difficulty answering questions
Slurred speech
Confusion
Doesn't understand instructions/conversation
Sleepy/lethargic

Elderly pt breakdown for AANP

65-84yo = young gerontologicals
85yo and older = frail elderly

Specific s/s related to iron def anemia

Pica
Koilonychia (spoon-shaped nails)

What is maculopapular?

Skin rash that has color (macular) and texture (small papules/raised skin lesions that range from red to bright pink)

Maculopapular rash w/lace-like pattern

Fifth dz

Maculpapular rash w/papules, vesicles, crusts

Varicella

Maculopapular rashes that are oval w/herald patch

Pityriasis rosea

Vesicular rashes on erythematous base

Herpes simplex
Genital herpes

Scabies

Excoriated pruritic rash on finger webs/penis
High risk: health care workers, anybody working with large populations
Tx: all family members/close contacts be tx'd at same time as pt; wash clothes/sheets in hot water, dry in high heat. Permethrin Rx.

Sandpaper texture rash w/sore throat, strawberry tongue, skin desquamination (palms/soles), no pruritic

Scarlatina

Papules that develop into bullae, rupture easily, become superficial, bright red weeping rashes w/honey-colored exudate, becomes crusted as it dries. Very pruritic, located on face, arms, legs.

Impetigo

Cutaneous larva migrans

Creeping eruption
Rashes shaped like red raised wavy lines, alone or few.
Red, very pruritic
Become excoriated from scratching (appears maculopapular).
Common on areas of body exposed to contaminated soil/sand (soles of feet, extrem., buttocks)
Tx: iverme

Info to know about drugs for cert exam

Generic name
Brand name
Drug class
Action
Indication
Common SE
Drug interactions
Contraindications
(Both names will be listed, but may also only be listed by drug class)

First line for AOM

Amox

Second line for AOM

Augmentin
Cefdinir (omnicef)

If pcn allergic, alternative for AOM

Azithromycin
Clarithromycin

Contraindications for pseudoephedrine (Sudafed)

Infants
Young kids
HTN

What is best location to hear S3?

Pulmonic area

What is diagnostic test for melanoma?

Bx

What is diagnostic test for septicemia?

Blood cx

What is diagnostic test for meniscus cartilage damage?

MRI

What is screening test for anemia?

CBC

What is screening test for HTN?

BP

What is screening test for TB?

Mantoux

What is screening test for UTI?

UA

What is best indicator of positive Mantoux/PPD?

Skin induration (erythema is NOT indication)
For positive = indurated and correct size (10mm)

What is gold standard for TB dx?

Sputum cx

What is tx for TB?

At least 3 antitubercular drugs (high resistance rates). When sputum cx and sensitivity come back, med can be narrowed down, changed, or another added.

Is TB reportable?

Yes (noncompliant pt's who refuse tx can be quarantined)

What baseline level should be checked before starting isoniazid (INH), and followed up on as well?

LFT

Other name for DJD

OA

Other name for atopic dermatitis

Eczema

Other name for senile arcus

Arcus senilis

Other name for AOM

Purulent OM

Other name for serous OM

OME
MEE

Other name for GAS

Strep pyogenes

Other name for tinea corporis

Ringworm

Other name for enterobiasis

Pinworms

Other name for vit B12

Cobalamin
Cyanocobalamin

Other name for vit B1

Thiamine

Other name for scarlet fever

Scarletina

Other name for OE

Swimmer's ear

Other name for conyloma acuminata

Genital warts

Other name for tic douloureux

Trigeminal neuralgia

Other name for tinea cruris

Jock itch

Other name for thalassemia minor

Thalassemia trait (either alpha or beta)

Other name for giant cell arteritis

Temporal arteritis

Other name for Psoas sign

Ilipsoas muscle sign

Other name for tinea capitis

Ringworm of scalp

Other name for light reflex

Hirschsprung test

Other name for sentinel nodes

Virchow's nodes

Other name for PPD

Mantoux
TB skin test

Other name for erythema migrans

Early Lyme dz

Other name for sinusitis

Rhinosinusitis

Who should be screened for suicidal/homicidal ideation?

All depressed pt's

Incorrect ways to ask about SI/HI

Statements that are judgemental, reassuring, vague, disrespectful, don't address issue in direct manner.

Most common psych disorders seen on cert exams

Major depression
ETOH abuse
Suicide risk

What drug class is first line for major depression and OCD?

SSRI

What is second line meds for depression?

TCAs

What meds are used for migraine prophylaxis, chronic pain, neuropathic pain?

TCAs

Why would you not prescribe TCAs for suicidal pt's?

For fear that pt will hoard drug and OD.
OD can be fatal (cardiac/CNS toxicity)

What are SSRIs first line for?

OCD
GAD
Panic disorder
Social anxiety disorder
Premenstrual mood disorder (fluoxetine, Prozac)

Examples of SSRIs

Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Sertraline (Zoloft, safest, oldest, most studied)
Paroxetine (Paxil)

Anticonvulsant used for chronic pain, trigeminal neuralgia

Carbamazepine (Tegretol)

How to answer questions of abuse

Pick open-ended question first
Interview pt and abuser together, then pt separetely

How to answer questions about depression

Pick statement most specific to find out if SI/HI
Don't pick answer that's judgemental/confrontational
Don't pick answers that reassure pt about their issues (discourages them from verbalizing more about it)
Don't ignore cultural beliefs

CAGE

Screening tool for possible ETOH abuse
2 out of 4 questions = highly suggestive of abuse.

What drugs are preferred in hypertensive pts w/osteopenia/porosis?

Thiazides (decrease calcium excretion by kidneys, stimulate osteoclast activity that helps w/bone formation)

Hypertensive pts w/migraines or diabetics who don't have chronic lung dz are good candidates for:

BB

BB are contraindicated in:

pt's with chronic lung dz (asthma, COPD, emphysema, chronic bronchitis)

Most common bacteria in AOE

Pseudomonas (bright green pus)

What is a possible complication of AOM?

Acute mastoiditis

Diverticula

Dx'd by colonoscopy
Asymptomatic, small, polyp-like pouches on wall of colon.
More common in Western society d/t low intake of dietary fiber.

How are mild cases of acute diverticulitis in stable pt's managed?

Outpt
Cipro 500mg PO BID plus metronidazole PO TID x10-14d

Rocky Mountain spotted fever

South central US
Classic rash: red rash, both wrists/ankles, spreads centrally w/involvement of palms/soles
Systemic s/s: high fever, HA, myalgia, nausea
Emergent (can cause death if not tx'd in first 8d of s/s)
From tick bite (Rickettsia rickettsi)
Tx: d

Lyme dz

Early = erythema migrans
Deer tick bite (Borrelia burgdorfi)
Tx: doxy x21d

ITP

Mild to severe
Plt are broken down by spleen --> thrombocytopenia.
Look for: easy bruising, petechiae, purpura, epistaxis, gingival bleeding (w/low plt)
Initial tx: glucocorticoids based on plt response
Most common found in 2-4yo
Preceded by recent (<4w)

Periods for up to 2y after first starting

May be irregular

Adolescent thinking

More abstract
Psychologically separating from parents
Opinions of peers more important than parents
Privacy!!!

What has second highest cause of mortality among adolescents and young adults (15-24) in US?

Homicide

What is a minor?

<18yo

What is emancipated minor?

<18yo who has full legal rights of adult:
Legally married
Enlisted in active duty
Has obtained emancipation through court

Can a minor parent give legal consent for their own care?

No, only for their child

Angina

CP precipitated by exertion, relieved by rest
Risk factors: low HDL, elevated lipids, age, gender

AAA

Pulsatile mass mid-abd a/w bruit
Risk factors: male, elderly, smoker, HTN, Caucasian, fam hx.
S/s: abrupt onset severe abd pain w/low back pain/abd distention with s/s shock.
Initial imaging diagnostic: abd u/s.

What ethnicity is Tay-Sachs most common among?

Eastern European (Ashkenazi) Jews
(Rare, fatal genetic disorder)

What test is best to assess renal function?

GFR (>60)

What affects serum creatinine?

Age (less sensitive in elder)
Gender (higher in males)
Ethnicity (higher in African background)

What is BUN?

Waste product of protein from foods you've eaten.

What can elevate BUN?

Dehydration
Eating more protein

Incubation period for scabies

3-4w
(Pts w/subsequent infections develop s/s in 1-3d)

Classic s/s of scabies

Itching worse at night
Rash that appears in new areas over time
Burrowing rash in webs of fingers

How is hep B transmitted?

Blood/body fluids

How is hep A transmitted?

Fecal oral routes (drinking contaminated water/eating contaminated food)

How long before PAP should pt avoid douching, sex, tampons?

48h

Acute bronchitis

Cough (most common symptom, appears after day 3)
Pharyngitis (early days)
Nasal discharge/congestion (early days)
Fever not typical (consider pna if present)

Modifiable risks for PAD

Hyperlipid
Smoking (most important risk factor)
HTN

S/s of neglect

Poor eye contact
Lack of animation
No social smile
Poor nutrition
Poor physical appearance

1st line for pna if S. pneumo suspected (abrupt onset of fever indicative)

Amox (2gm BID adults, 80-100mg/kg/d kids)

1st line for atypical pna (common in peds >5yo)

Azithromycin

Normal resp rate for 18mo

20-30bpm

MVP typical clinical course

Benign
Most pt's asymptomatic
Murmur may be present (best heard w/diaphragm over apex).
Few pt's: HF s/s (usually result of MR) or sudden death may occur.

Overflow incontinence

Typically has secondary cause (BPH, trauma, surgery, neuro condition)

Pelvic floor muscle training

Kegel exercises most common/easiest, used to strengthen pelvic muscles, improving stress/urged/mixed incontinence.

What skin lesion fluoresces under Wood's lamp?

Hyphae (fungal)

1st line tx for BV

metronidazole 500mg BID x7d (NO ETOH: can produce disulfiram reaction)
Tinidazole can also tx if metronidazole fails (has longer half-life)

Hypothyroidism

TSH >5 x2 w/symptoms
Fatigue
Wt gain
Dry skin
Cold intol.
Constipation
Menstr. irreg.
Hair/nail breakage

Which WBC should be present in greatest number in healthy pt?

Neutrophils (60-70%)
AKA Polys or segs

Eye red flags

Red/painful eye
Photophobia
FB sensation
Sudden onset of pain
REFER to ophthalmology!
Differentials: bact conjunct., keratitis, active corneal process, glaucoma

Pityriasis rosea

Viral rash
Common in older peds/young adults
Typically starts w/herald path (single round pink/salmon colored, nonpruritic plaque)
On chest/neck/back
Often mistaken for ringworm before Christmas tree pattern (occurs 1-2w after herald patch appears)

Nursemaid's elbow

Subluxation of radial head
Usually no pain until someone attempts to move elbow
Arm slightly flexed, held close to body
Occurs after pulling upward abruptly
Reduction: hyper pronate FA

Most common s/s GERD

Heartburn (esp postprandial)
Regurgitation
Dysphagia (esp after longstanding heartburn)

Definitive dx of sickle cell

Hgb electrophoresis
Initially suspected on visual exam of RBCs (sickle shaped)
Can be ID'd as early as 3mo
Once + screen, repeated w/either hgb electrophoresis or DNA analysis.

Risk factors for osteoporosis

Age >50yo
Steroids (chronic)
Low body wt
Smoking
RA
Previous fx
Parenteral h/o hip fx
Caucasian/Asian
Excessive ETOH

When should another antidepressant be tried if SSRI is not helping?

8-12wks at max dose

Shingles

Vesicular rash
Burns, itches
Painful neuritis
Tx: PO antiviral within 72h of onset of s/s (shortens severity/duration, may help decreased incidence of post-herpetic neuralgia)

Toxoplasmosis

Infection from parasite Toxoplasma gondii
Can result in fetal demise
Preg pt's should avoid contact w/cats, esp feces.
Can be acquired by eating undercooked meat (lamb, venison, pork), gardening (cats poop in soil)

ALL

Plt count low (thrombocytopenia)
Other WBC abnormalities
2-5yo peak
Bleeding
Fever
Lymphadenopathy
Nonblanchable rash over joints
Easy bleeding/bruising

Septic arthritis

Characterized by elevated WBC

Von Willebrand's

Common autosomal dominant bleeding disorder that may include easy bruising/prolonged bleeding, but has normal plt.

Multiple myeloma

Neoplastic proliferation in bone marrow (plasma cells).
Results in skeletal destruction.
More common in geri (ave 66yo)
Pain in long bones (esp trunk/back)
Anemia (normocytic/normochromic)
Hypercalcemia
Renal insuff.

Plantar fascia best examined:

With great toe dorsiflexed (examining for plantar fasciitis)
Palpate plantar fascia on sole of foot
Anterior heel pain usually easily appreciated

Most effective intervention for viral gastroenteritis

Oral rehydration
Treat symptomatically
Goal: prevent dehydr., replace lytes.
Be careful in geri/kids <5yo: antidiarrheals, antispasmodics, antiemetics (use clinical judgement)

NSAID contraindications

Renal insuff. (may produce transient decrease in renal function; likely produces Na retention, thus water retention; may worsen HTN because of this).

Persistent generalized lymphadenopathy

Enlarged lymph nodes in at least 2 noncontiguous sites other than inguinal nodes.
Seen during asymptomatic HIV infection.
Lymphatic tissue serves as primary reservoir for HIV.

How much wt loss is normal for infant in first 3-4 DOL?

10% of birth wt (will rapidly gain this back)
Continue feeding every 2-4h, return at 2mo WCC

65yo DM pt on PO antihyperglycemics, still having poor control. AM FBGL 140-160. What next?

Add insulin 10u long-acting at bedtime

Polymyalgia rheumatica

Chronic inflammatory condition
Produces morning neck/shoulders/hips stiffness.
Peak incidence: 70-80yo.
Commonly a/w temporal arteritis.

Temporal arteritis

Chronic vasculitis of med. and Lg vessels.
Characterized by new onset unilat temporal HA, abrupt onset visual disturbances, elevated ESR, jaw claudication, unexplained fever.
Best dx'd by temporal artery bx.
Commonly a/w PMR
Refer to neuro.

Vit B12 deficiency

Can produce anemia called pernicious anemia.
Most common in geri
Characterized by macrocytosis (increased MCV, so RBCs are larger than expected).

Microcytosis

Seen in IDA, thalassemia (decreased MCV, RBCs are smaller than expected)

Leukocytosis

Large numbers of WBCs in blood
Often seen w/bacterial infections

Fractures

Swelling
Pain
Decrease mobility
No single s/s can rule out
Usually d/t trauma
Pathologic: tumor, osteopor., cancer.

Serum ferritin

Helpful in eval of IDA
Demonstrates amount of Fe in storage
Used to determine if Fe levels have been corrected (can stop supplementation when ferritin WNL)

How often should lipids be checked if pt 65yo and older, have lipid disorders or CV risk factors?

Annually
(every 5y for pt's at low risk)

Shingles vax

Contains more virus than varicella vax
Give to all immunocompetent 60yo or older x1
Can be given as early as 50yo

How to remove tick

Use tweezers to pull it off
Don't crush it!
Wash skin after
If mouth parts stay: don't remove (they come off on their own)
Monitor x30d for erythema migrans

PSA level is influenced by:

Age, race, volume of prostate tissue

Test for initial screen for hep C infection

HCV antibody test (anti-HCV)
Detectable antibodies usually occur 2-6mo after exposure

Confirmatory test for hep C exposure

HCV RNA (once nonreactive, no need to retest)

What indicates immunity to hep B?

+ hep B surface antibody (anti-HBs) with - core antibody (anti-HBc)

Colic

Symptom complex characterized by episodes of inconsolable crying w/apparent abd pain
Usually 1-3mo in very predictable pattern, usually in evening after feeding
Meds, formula change not indicated
Educate parents about colic, comfort measures (rhythmic roc

When does a child's vision approximate 20/20?

5-6yo

Standard practice for rubella titers in preg.

Ensure that protective rubella titer exists in women who are preg now.
If preg pt had protective titer in previous preg, re-eval not necessary.
Protective usually = 1:10 or more.
If titer negative, vax AFTER delivery.

What causes the cough a/w ACEi?

Due to buildup of bradykinin.
Bradykinin: partly degraded by ACE --> this + conversion of angiotensin I to II by ACE occurs in lungs --> when degradation impaired (like with ACEi), bradykinin can accumulate --> cough!
Typically dry, nonproductive
More com

Recommendation for flu vax in preg

ALL preg women get INACTIVATED regardless of preg stage.
Preg pt's = at increased risk of severe medical/preg complications a/w infections from flu.
Passive protection to baby when mom is vax'd.
NO LIVE NASAL SPRAY!!!!

Common s/s of gonorrhea

Dysuria
Purulent inflammation
Urethral discharge
(Presentation varies)

How can gonorrhea be dx'd?

Urethral cx (vag swab, preferred in adult females)
Urine screen (1st choice in male, adolescents, peds)
Nucleic acid tests

Risk factors for drug resistant strep pneumo (DRSP)

>65yo
Beta-lactam, macrolide, resp quinolone in last 3mo
Alcoholism
Medical comorbids
Immunosuppressed
Exposure to child in daycare

1st line for T2DM

Metformin

Malpractice

Must be a duty, breach of duty, and subsequent injury due to breach: must all be present for malpractice to be defined.

Common meds that are ototoxic

ASA
Aminoglycosides
Vanc
Erythromycin
Loop diuretics
Antimalarial meds
Sildenafil
Tadalafil
Vardenafil
Cisplatin

What puts some pt's at increased risk for ototoxicity secondary to meds?

If they have impaired renal function (makes excretion of ototoxic drug more difficult, builds up, ototoxicity more likely)

What is Osgood-Schlatter?

Osteochondritis of tibial tubercle
Produces pain in knees (adolescents)
Pain gradually increase over time, can become severe (esp. if knee has direct hit, or when pt kneels)
Dx made on clinical presentation (no need for imaging)
Tx: RICE, NSAIDs, strength

AM fasting glucose goal for elderly w/T2DM

80-130
Risk of hypoglycemia present
Goal peak postprandial FSBS = <180
Hypoglycemia in sleep can cause CVA/Sz in elderly

DSM-5 criteria for anorexia nervosa

Restriction of energy intake leading to low body wt
Significantly low wt (<minimally normal for adults, <minimally expected for kids/adolescents)
Intense fear of wt gain/getting fat, persistent behavior that prevents wt gain
Distorted perception of body w

Best test to eval murmur in preg pt

3D echo (best for preg and nonpreg)

Most common murmur in preg

Venous hum murmur (benign, resolves w/in several wks after delivery)

3 day old full-term infant has bili of 16. Management?

Phototherapy (since bili will probably rise a bit more)
(16 = high intermediate)

1st line tx for male UTI

Bactrim x7-10d

Medicare Part B

Pays:
Examiner
Outpt care
Ambulatory surgery services
XR
DME
Labs
Home health
Pt's can pay for w/monthly option (based on income)
There's initial copay, so may NOT pay for today's visit

Plaque psoriasis

Seen initially in young adults
Chronic
Thick, silvery scales (scalp, extensor surface of elbows/knees/back)
Usually asymptomatic (some have pruritis)
Pitting fingernails (50% of pt's)

Are leukotriene blockers ever used in COPD?

No

Stage I (Mild) COPD management

SABA prn OR SAAC prn
If SABA unavailable, consider slow release theophylline

Stage II (Moderate) COPD management

LABA bid
SABA prn OR SAAC prn
Rehab

Stage III (Severe) COPD management

LABA bid
SABA prn OR SAAC prn
Add ICS if repeat exacerbations
Rehab

Stage IV (Very Severe) COPD management

LABA bid
SABA prn OR SAAC prn
ICS if repeat exacerbations
Add long term O2 if chronic resp failure
Consider surgical tx
Rehab

Most common cause of pna in 6mo-5yo

Viral (RSV usually)

Most common cause of pna in very young children (>5yo)

Atypicals (Mycoplasma, Chlamydia)
S. pneumo

Most common cause of pna in elderly

S. pneumo

Most common cause of pna in young/middle adults

Atypicals (Mycoplasma, Chlamydia)

How is bacterial sinusitis transmitted?

All bact. infections of upper resp tract transmitted by direct contact w/fomites, secretions, or resp droplet.

What can be done to prevent RBC lysis in pt w/Glucose-6-phosphate dehydrogenase deficiency (G6PD)?

Avoid ASA, sulfa, fava beans

What is G6PD?

Glucose-6-phosphate dehydrogenase deficiency
Most common enzymatic RBC disorder in humans
X-linked disorder (carried on X chromosome)
Seen in males & females

Stress fx

Common w/abrupt increased activity (marching)
Stress fx of metatarsals AKA "march" fx
More common w/flat feet
2nd, 3rd, 4th metatarsals = 90% of metatarsal stress fx

How often should CD4 be checked if pt stable on therapy?

Every 3-6mo (unless condition/status changes)

When should CD4 be checked after initiating/changing therapy?

Every 2-8w

How often should CD4 be checked in asymptomatic HIV pt?

Annually, unless condition/status changes

Ankle sprain management

RICE
Can do NSAIDs prn
XR NOT needed

Grade I sprain

Minimally torn ligament
Stable joint

Grade II sprain

Incomplete (partial) tear
Moderate instability
Pain w/wt bearing
Moderate-severe pain/swelling

Grade III sprain

Completely torn ligament
Unstable joint
Unable to bear wt
Severe pain/swelling

Is sertraline safe in preg?

Yes
Always advise caution, but little reports of teratogenicity in 1st trimester.
Weigh risks/benefits
OB and Pt should make joint decision

Do psychotropics cross placenta?

Yes, ALL do!

What is ALWAYS present w/COPD pt?

Obstructed airways (NOT completely reversible)

Does cough occur in COPD and emphysema?

COPD = yes
Emphysema = not necessarily

Is SOB always present in COPD?

No

Is hypercapnia more prevalent in emphysema or COPD?

Emphysema (air trapping occurs)

Is shingles vax live?

Yes

What should be suspected if nasal septal erosion or perforation present?

Sniffing toxic substances like cocaine

Tx for eczema/atopic dermatitis under normal conditions

Keep well-lubricated w/emollients
Use liberally as often as needed to prevent dry skin (more prone to exacerbations)

Tx for eczema/atopic dermatitis exacerbation

Topical steroids (use lowest potency that resolves it)

Cotton wool spots

Small dull, yellow-white coloration on retina.
D/t swelling of retinal surface layer because of impaired blood flow to retina.
Most common cause: DM and HTN.

Fundoscopic microaneurysm

Earliest manifestation of diabetic retinopathy.
Small, round, dark red dots on retinal surface.

Fundoscopic exudates

Accumulation of proteins/lipids.
Bright, reflective white/cream lesions on retina.

2nd leading cause of cough in adults

Asthma

Cough variant asthma

Pt's that have asthma but only cough

Mild intermittent asthma

s/s </= 2d/wk
OR
</= 2nights/mo
(Exacerbations brief)

Mild persistent asthma

s/s >2/wk, but not daily
OR
3-4/mo at night

Moderate persistent asthma

Daily s/s
OR
>1night/wk (but not nightly)

Severe persistent asthma

s/s throughout day
Often 7nights/wk

How do thiazides improve osteoporosis?

Increases serum calcium levels by decreasing fluid, making more available for absorption.
Stimulates osteoclasts
Don't use to TREAT osteoporosis, but if pt has HTN AND osteoporosis, had the additive benefit of helping the osteo.

PSA velocity eval

Requires 3 serial readings over 12-24mo.
>0.35/year = a/w high risk of death from prostate cancer.
Pt needs bx by urologist.

Clinical eval of breast mass

Start w/good H&P.
Ask if mass changes at time of menses.
>30y = mammo
U/S = to eval focal abnorm., esp if ID'd on mammo.
<30yo = depending on H&P, maybe reassess 3-10d after next menses

BP/HR changes in 2nd preg trimester

BP decreases (5-10) d/t reduction in systemic vascular resistance.
HR increases (10-15)

What is commonly seen when oral swab is done on HIV+ pt?

Yeast (common w/thrush, which is common in HIV+ pt's; usually indicates Candida)

MCH

Mean Corpuscular Hgb
Indicates how much hgb is in RBCs (color).
Normal range = normochromic

What is used to dx COPD?

PFTs or spirometry (FEV1 & FVC)

Stage I Mild COPD

Mild airflow limitation
FEV1/FVC <70%
FEV1 >/= 80% predicted (w/or w/out s/s)

Stage II Moderate COPD

Moderate airflow limitation
FEV1/FVC <70%
FEV1 50-79% predicted

Stage III Severe COPD

Severe airflow limitation
FEV1/FVC <70%
FEV1 30-49% predicted

Stage IV Very Severe COPD

Very severe airflow limitation
FEV1/FVC <70%
FEV1 <30% predicted
OR
FEV1 <50% + chron resp failure

Subjects in research study who don't have dz/condition, but included for comparison

Controls

Geri (>60yo) initial dose of levothyroxine

25mcg

Initial dose of levothyroxine for 60-60yo

50mcg

What will increase after thyroid supplementation is initiated?

ALL metabolic processes!

In what increments are dose increases in levothyroxine?

12.5-25mcg every 4-6w until euthyroid

Initial management of trauma that results in acute pain

XR

What occurs in BV?

High concentrations of anaerobic bacteria replace normal vaginal flora --> "fishy" odor, itching, vulvovaginal pruritis/burning, unpleasant odor after coitus.

Normal HR for 10yo

60-100

Normal HR for 4-6yo

60-140

Initial interventions for 8wo w/GERD

Don't overfeed (small, frequent feedings)
Thicken milk (decrease frequency of reflux)

Management for persistent GERD in infants w/low wt

All of the initial interventions PLUS increase caloric content

Meds for GERD babies

PPI

40% of infants w/GERD are sensitive to:

Cow's milk protein (may need to do milk-free diet)

Trazadone

TCA
Can cause profound drowsiness.
Take at bedtime.
Indicated for insomnia r/t depression or alleviate jitteriness/restlessness a/w SSRI/SNRI

Contraindications for TCA

Conduction problems
Arrythmias
Narrow angle glaucoma
Urinary retention
Orthostatic hypotension

TCA cautions

Elderly (b/c of anticholinergic SE)
Assess SI (OD can be lethal)
Get EKG before starting

2nd line Rx for AOM

Macrolides

Possible etiology of 6 day old w/bilat mucopurulent eye discharge

Mom has chlamydia
Vaginal births: 60-70% chance baby will get C. trachomatis.

NB born vaginally to moms w/chlamydia may present w/:

Pna
Conjunctivitis

When does conjunctivitis usually occur in vaginally-born baby if mom has chlamydia?

5-14d after delivery

Tx for NB chlamydia conjunctivitis

PO erythromycin 50mg/kg/day divided x14d
For pna AND conjunctivitis

B12 deficiency can produce:

Pernicious anemia (characterized by macrocytic cells)

Management for pt w/strep throat taking azithromycin x48hrs w/no improvement

Consider changing to PCN or cephalosporin w/beta lactamase coverage.

What common abx has high rates of Strep resistance?

Macrolides

Most important assessment for adolescent female who is amenorrheic

Tanner stage

Start screening for renal nephropathy in T2DM at:

Diagnosis!
Nephropathy takes yrs to develop, but present in ~30% of diabetics.

How often do you screen for renal nephropathy in diabetics?

Annually

Diabetic renal nephropathy definition

Presence of DM and >300 albuminuria x2 3-6mo apart

What complication should always be considered in female on OCPs?

DVT
CVA
PE
MI

Common s/s of pna

Fever
Cough
CP
Dyspnea
Sputum production
Infiltrates on CXR (dx)

1st line Rx for BGL >300 w/symptoms

Insulin
Can be dx'd as diabetic today!
PO won't have much effect right now.
Insulin will give PO agents a chance.
Return next day for recheck and med adjustments.

ADA A1C Criteria for DM dx

>/= 6.5% confirmed PLUS repeat on another day or other elevated BGL method

ADA FPG Criteria for DM dx

>/=126 confirmed PLUS repeat on another day or other elevated BGL method

ADA 2HPG/OGTT Criteria for DM dx

>/= 200 during OGTT w/75g glucose load PLUS repeat on another day or other elevated BGL method

ADA random BGL Criteria for DM dx

>/= 200 PLUS classic s/s of hyperglycemia crisis

Standard for fecal occult blood tests

3 consecutive specimens needed (2 samples per card)

76yo F w/DM, HTN, hyperlipids, new onset afib. She's at risk for:

HF

When afib develops, what % of cardiac output is lost?

30% (amount contributed by atria when not in afib)

Common s/s of HF

SOB
Periph edema
S3 gallup

Most serious risk of afib:

CVA

Barlow and Ortolani

Used to assess for DDH birth to 3mo (every visit)

Primary imaging for assessing DDH birth to 4mo

U/S (limited by ultrasonographer experience)

Primary imaging for assessing DDH >4mo

AP XR (frog leg)

Joint space narrowing

Articular cartilage loss.
Worsening OA (can also be seen in RA, ankylosing spondylitis, some connective tissue disorders).

Osteophytes

Form in response to cartilage degeneration in joints

McMurray Test

Used to assess joint motion/meniscal injury
+ if painful "click" during early/mid-extension of knee or if pain along joint line during test.
+ = meniscal tear

Supplement known to cause constipation

Calcium (need to increase fluids/fiber to combat)

If elder abuse is suspected, what should you do?

Report it

First age to safely give MMR

12mo

When is MMR repeated?

Once at 4-6yo

Chronic skin disorder primarily in hairy body areas

Seborrheic dermatitis
Causes skin flaking (usually scalp).
Adults/adolescents = dandruff.
Babies/kids = cradle cap.
Unknown cause
Greasy/flaky
Can be seen in pt's w/PD

MCV

Mean corpuscular volume
Indicates size of RBCs
WNL = normocytic

Most effective way to decrease risk of spina bifida

Folic acid in/before preg (8)

Role of folate

Amino acid/DNA synthesis

2nd most common congenital anomaly

Spina bifida

Earliest that pubertal changes should occur in males or females

9-10yo

Pubertal changes <9yo in males or females

Precocious puberty possible

OA

Characterized by destruction of articular cartilage.
Men: more common <45yo
Women: more common >55

Most common joints affected in OA

Fingers (primary)
Knees
Hips
Spine

Chronic prostatitis s/s

Urethral irritation after voiding
Sometimes perineal pain
May have normal prostate

Acute bacterial prostatitis s/s

Fever
Chills
Prostate: tender, boggy

Epididymitis s/s

Scrotal pain/heaviness
Pain w/defecation
Epididymal tenderness
No prostate abnormalities

ASA MOA

Inhibits enzyme cyclooxygenase.
Reduces thromboxane A2 production, which stimulates plt aggregation.

Most likely etiology of aortic stenosis in <65yo

Congenital

2nd most common cause of aortic stenosis

Rheumatic heart dz

Most likely etiology of aortic stenosis in >65yo

Acquired calcifications

Adult w/URI s/s and cough x >5d:

Consider pertussis

Incubation period for pertussis

7-10d

When does classic pertussis paroxysmal cough usually begin?

2nd week of illness

Duration of s/s of pertussis

About 3mo, even w/abx

Is pertussis reportable?

Yes (highly infectious)

Preg pt is likely to have following heart changes:

Venous hum murmur and S3

Abnormal murmurs in preg

Mitral stenosis
Aortic regurgitation

Typical findings w/BPH

Prostate: firm, smooth, symmetrically enlarged, nontender.
Difficulty initiating stream (early symptom)

Prostate cancer s/s

Asymmetric enlargement
Induration
Nodules

Water heater temp setting for geri/peds to prevent burns

<120 degrees

SSRI full effect

Greater than 4w (usually 8-12)

SSRI has increased risk of bleeding w/:

ASA
NSAIDs
Warfarin

Monitor w/SSRI

Hyponatremia
Hypoglycemia

SSRI drug-drug interactions

Potent inhibitors of P450 isoenzymes inhibiting metab of other drugs leading to toxicity:
TCA
Antiarrhythmics
Neuroleptics
Warfarin
BB
Serotonin syndrome risk:
Dextromethorphan
MAOIs (wait at least 5w after taking)
TCA
Triptans

Goal BP for HTN w/T2DM

<140/90 (if high risk for CVD = around 130/80)

What age do s/s of IBS start?

<50yo

Typical s/s of IBS

Intermittent diarrhea/constipation
Abd pain (dx criterion)
Bloating

Other name for club foot

Talipes equinovarus

Common findings w/club foot/talipes equinovarus

Accompanied by smaller/shorter leg/calf on affected side.
Foot is plantar flexed.
Forefoot/sole are thrust medially.

NP's role in club foot finding

Refer urgently to ortho

Management of club foot

Initially: casting/splinting
May need surgery after 3-6mo.

How are majority of club foot pt's corrected if early intervention?

Taping, splinting, and/or casting

Tx for gonorrhea

Ceftriaxone 250mg IM PLUS azithromycin 1g PO
Report tx failure to CDC

Increased risk for T2DM

>/=45yo
BMI >/= 25
1st degree relative w/DM
Asian
Latino
African American
Pacific Islander
Native American
Phys inactivity
F delivered baby >9lb
F dx'd w/gest DM
HDL <35
TGL >250
A1C >/= 5.7%
IFG or IGT on prev testing
HTN
Insulin resistance (severe obesi

S/s complicated GERD

Choking
Cough
SOB
Pain w/swallowing
CP

Tx for uncomplicated GERD

Empiric (PPI or H2B)

PPI MOA

Reduce gastric secretion by binding to/inhibiting hydrogen-potassium ATPase pump

Common PPIs

Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Esomeprazole (Nexium)
Pantoprazole (Protonix)

H2 Blockers MOA

Decrease acid secretion by inhibiting H2 receptors on gastric parietal cells

Common H2B's

Ranitidine (Zantac)
Cimetidine (Tagamet)
*Famotidine (Pepcid)
*Nizatidine (Axid)
*Preferred b/c of efficacy, low risk of drug-drug interactions

Antacid MOA

Neutralize hydrochloric acid in stomach to rapidly increase gastric pH

Common Antacid

Tums (calcium carbonate)

Management of GERD if s/s persist despite initial tx or if s/s severe

Testing to rule out esophageal cancer, Barrett's, etc.

Vast majority of breast lumps:

Are benign (but eval for breast cancer, esp. elderly).

Fibroadenomas are common among:

Younger women

Breast cysts are common:

Throughout the lifespan

Most commonly used med to tx essential tremor

Long-acting propanolol

Most common movement disorder

Tremor

Most common of all tremors

Essential tremor

Essential tremor is characterized by:

Rhythmic movement of body part (hands, head).

Typical age for stranger anxiety

7-36mo (most specific: 9mo)

Positive TB skin test criteria for >/= 5mm

Close contact w/known or suspected active TB pt.
HIV + pt's
Organ transplant pt's
CXR: active or prev. active TB

Positive TB skin test criteria for >/= 10mm

Clinical conditions that increase risk of TB
Recent immigrants
IV drug users
Residents/employees in high risk settings
<4yo
Peds exposed to adults at high-risk

Positive TB skin test criteria for >/= 15mm

No prev. defined risk factors for TB

ACS description

STEMI
NSTEMI
Unstable angina
Almost always a/w atherosclerotic plaque rupture & partial/complete thrombosis of the artery.

ACS etiology

Coronary thrombosis (plaque rupture)
Coronary artery vasospasm

ACS risk factors

Fam h/o CAD <60yo
Hyperlipids
Men >40yo
Women post-menopause
Smoking
HTN
Sedentary life, obesity (esp. central)
DM
Metabolic syndrome
Stressful life
Preeclampsia, gest DM, preg induced HTN
Coronary calcification, carotid plaque
Lupus, RA

ACS PE findings

Pain, pressure, squeezing, burning in chest (maybe radiates to neck, shoulder, jaw, back, abd, arms); lasts >20min, esp. if no relief from NTG.
Increasing severity
N/V
Diaphoresis
Weakness/syncope
Impending doom
HTN/hypo
Palpitations
Dyspnea relieve w/res

ACS complications

Pulm edema
MI

ACS diff. dx

Esoph. spasm
Gastritis
Pericarditis
Costochondritis
Pulm. emb.
Anxiety

ACS dx studies

EKG! (may show transient ST elevations, dynamic T wave changes, ST depressions, q-waves)
Trop I
CKMB
Coags (PT, INR)
CBC
CMP
Lipids
TSH
CXR
Angiography
Echo
CT w/contrast or MRI

Troponin I

Detectable 3-6hrs after MI.
Peaks 16h
Declines over 9-10d
If -, then repeat in 8-12h

What is the best marker of cardiac damage?

Trop I (more sensitive/specific than CKMB)

CKMB

Indicative of MI

ACS pharm

Nitrates
BB
ASA, Plavix, LMWH, unfractionated heparin

Goals during ACS

Stabilize pt
Relieve pain
Re-establish perfusion (angiography/surgery)
Antithrombotics
O2
Morphine

How do nitrates help during ACS?

Vasodilation --> improves collateral blood flow, decreases preload/afterload

How do BB help during ACS?

Reduce O2 demand/ventricular wall tension
Decrease mortality
May prevent mechan. complications (papillary musc., L ventricular free wall, ventricular septum rupture)

Contraindications to BB

SBP <90
Cardiogenic shock
Severe bradycardia
2nd/3rd degree block
Asthma/emphysema
PVD
Uncompensated HF

Post-MI goals

Modify CAD risk factors
Low fat diet
Smoking cessation
Regular, aerobic exercise
Stress reduction/management
Med compliance

ACS referral from primary care:

ED stat

What should you do if pt has ACS while in primary care setting?

ASA stat
O2
NTG
TRANSPORT TO ER!!!

Stable angina description

Substernal pain/discomfort when myocard O2 demand > myocard O2 supply --> myocard ischem.
Some pt's asymptomatic
Usually predictable w/exertion and relieved by rest/NTG

Stable angina etiology

CAD
Coronary artery vasospasm
Coronary artery thrombosis
Aortic stenosis/insuff.

At what age is stable angina most common?

50-70's

Stable angina risk factors

Fam h/o heart dz
HTN
Hypercholest.
DM
Smoking
Cocaine
Phys. inactivity
Obesity
Men >45yo
Women >55yo

Nonmodifiable risk factors for stable angina

Age
Gender
Race

Other name for stable angina

Angina pectoris

Angina triggers

Very hot/cold weather
Phys. activity
Emotional stress
Large meals
ETOH
Smoking

What is the duration average of s/s stable angina?

2-5min

Stable angina diff. dx

Esophagitis/esoph. spasm
Gastritis/PUD/GERD
Pericarditis
PE
Costochondritis
Pneumothorax
Chest wall syndrome
Cholecystitis
Anxiety
Aortic dissection

Dx of stable angina

Usually based on H&P & EKG

Initial test for stable angina

EKG (may have ST depression, T inversion, rhythm disturb., may be normal when no CP)

Dx studies for stable angina

H&P
EKG
CXR
CMP
Lipids
Trop
CK/CKMB
BNP if suspected HF
Echo
Stress test
Angiography

NonRx management stable angina

Smoking cess.
Phys. act. 30-60m x5-7d/wk
Cardiac rehab if neces.
Wt loss if neces.
Stress management
ETOH: 1/day (women), 2/day (men)

Stable angina prevention

Med. compliance
Modify risk factors
Low fat diet
Control HTN, hyperlip., DM
Smoking cess.
Exercise

Recommended meds stable angina

ASA
Plavix if ASA contraind.
BB
ACEi or ARB (HTN, DM, CKD)
CCB (not if on BB too)
Long/short-acting nitrates

Warfarin management

Start at 5mg (maybe 2.5mg if elderly, liver dz, HF)
Check INR after 2-3 doses,
THEN
Biweekly until target INR,
THEN
Weekly,
THEN
Biweekly,
THEN
Monthly,
THEN
Q3mo when 3mo of consistent therap. INR.

Is warfarin safe in preg?

No in general
Yes, but with LOTS of caution if pt has mechan. heart valve.

Is warfarin safe in breastfeeding?

Yes

Congen. heart dz description

Results from >/=1 struct. abnorm. that develop before birth.
Become evident at birth, infancy, young adulthood.

Classifications of CHD

Cyanotic
Acyanotic

Etiology of CHD

Who knows?!

CHD contributing factors

Mom:
Age >40yo, ETOH, amphetamines, anticonvul., lithium, progest./estrog.
Viral infec:
Rubella
Coxsackie B
Enteroviruses
Med. conditions:
DM
SLE

CHD chromosomal associations

Trisomy 21/13/18
DiGeorge
Cri du chat
Turner's

CHD presentation

Central cyanosis
Murmur
Tachypnea/resp. distress
HF
Poor CO (poor pulses, mottling, hypotension, metab. acidosis, circul. compromise)
Abnorm. heart rhythm (Tachy, brady, heart block)
Abnorm. heart size, shape, location

CHD diff. dx

Innocent murmur
Pulm. dz
Cyanotic vs acyanotic dz
Metab. abnormal.
Thyrotoxicosis
Dysrhythmias

CHD dx studies

CXR
EKG
Echo
ABG
Cath/angio
Heart CT
TEE

DVT description

Blood clot in veins of extrem/pelvis.
Can migrate to lungs.

DVT Etiology

Virchow's Triad:
Blood flow alteration (stasis), vasc. injury, alterations in blood components.

DVT risk factors

Immobility >4h
Malign.
Lower extr. trauma
Obesity
Preg./postpartum
OBC
Hormone replacement
Smoking
Recent surg.
Fam/person hx
>60yo

DVT presentation

Initially asymptom.
Pain
Warmth
Erythema
Tender
Edema
Difference in calf diam.
Palp. cord over affect. vein
Positive Homan (unreliable)

DVT diff. dx

Musc. strain/tear
Paralyzed limb swelling
Lymphangitis
Cellulitis
Baker's cyst
Superficial thrombophleb.
Venous insuff.

DVT dx studies

PE (30% accurate for dx)
DDimer (high sens., not spec.)
U/S (affect vein not compress. = dx)
Contrast venography if can't do U/S
CBC
PT, PTT, INR
Renal function

DVT tx length

Anticoags 3-12mo (depends on etiol.)
Compress. socks (30-40mm) x1-2y

HF description

Heart can't meet metabolic tissue demand

HF classification systems

NYHA
ACCF/AHA

ACCF/AHA Stage A HF

High risk, but no dz or s/s

ACCF/AHA Stage B HF