Rotations - Family Med

Front 1

Cough

1) What are 9 common causes of cough?
a) 3 MC bacterial causes of URI --> WHAT --> cough?
b) 5 MC viral causes of URI --> cough?
c) What is the MC irritant associated w/ cough?
d) MC of cough overall?

2) Cough Pathogenesis:
a) Describe the pathogenesis by which Irritants cause cough?
b) Describe the pathogenesis by which bacterial or viral URI can cause cough?
c) What 2 causes of cough directly stimulate the cough reflex?

3) Cough Hx
a) Acute cough is considered a cough lasting how long?
b) Chronic cough is considered a cough lasting how long?

4) Cough Hx Cont'd: Match the following hx w/ type of cough?
a) Seasonal pattern of cough?
b) Nocturnal cough?
c) Cough w/ meals?
d) Exercise or cold induced cough?
e) Cough on exertion?
f) Productive cough?
g) Dry cough?
h) Itching sensation @ back of throat?
i) Cough w/ Hemoptysis?
j) Wt loss + Chronic cough = you should consider what?
k) PND --> cough in what 2 major populations?
l) 4 Rx --> cough?
m) Child w/ chronic cough (> 8 wks) = you should have what 2 things on top of your ddx?
n) Describe the cough seen in asthma?
o) Chronic cough resulting from lung CA or TB will be accompanied by what 3 other sx?
p) cough worse w/ lying down?

Back 1

1) Allergies;
Asthma;
Bacterial or Viral URI;
CA;
Cardiac dz;
COPD;
GERD;
Irritant exposure;;
Psychological
a) S. pneumo; H. flu; M. pneumoniae -->
Sinusitis, Pharyngitis, Bronchitis, Pneumonia -->
Cough

b) Influenza;
Parainfluenza;
Rhinovirus;
Adenovirus;
RSV
c) Cigarette smoke
d) Viruses

2)
a) Irritants damage cilia of tracheal Ciliated Pseudostrat Columnar Epi -->
Microscopic particles can now reach the lungs -->
Microscopic particles stimulate aff cough receptors -->
Stim of Phrenic Nerve, V, IX, X -->
Stim medullary cough center
b) bacteria and viruses -->
inflamm and inc mucous secretion -->
Stim aff cough receptors
c) CA;
Foreign body

3)
a) < 8 wks
b) > or = 8 wks

4)
a) Cough secondary to allergic rhinitis
b) Asthma;
GERD;
PND;
CHF
c) Aspiration
d) Asthma
e) Cardiac etiology
f) Infxous: Bronchitis, Pneumonia
g) PND or asthma
h) PND
i) TB or CA
j) CA
k) Allergies and / or recent URI
l) ACE I;
Amiodarone;
beta blocker (asthma pts, etc...);
Nitrofurantoin (secondary to pulm fibrosis)
m) Asthma and/or Allergies
n) Dry (non-productive) an worse @ night, w/ exercise or cold air
o) wt loss, night sweats, hemoptysis
p) GERD

Front 2

5) Cough PE
a) 5 areas of focus in your PE for pt w/ cough?
b) Why do you look in ears in pt w/ cough?'
c) 2 reasons why you look in the nose in pt w/ cough?
d) 2 reasons why you look in the throat in a pt w/ cough?
e) Why do you examine the neck in a pt w/ cough?
f) 4 reasons why you examine the chest in a pt w/ cough?

6) Diagnostic Eval & w/u of Cough
a) How to w/u cough of suspected viral et?
b) How to w/u cough that you suspect is caused by sinusitis?
c) How to w/u cough that you suspect is caused by ACE I?
d) When would you include a CXR in the w/u of a cough?
e) What is the most likely et of cough in Immunocompetent pts w/ persistent cough and normal CXR?

7) Tx of Cough
a) Is cough a sx or a dx? TF what?
b) So BL, their are 2 types of tx of cough. What are they?
c) 2 Tx options for Chronic cough (>8wks)? What do they act on?
d) 2 major tx options for acute cough due to common cold?
e) Give 1 mucolytic agent that can be used to tx cough? MOA?

Back 2

5)
a) Ears, nose, throat, neck, chest
b) Ears plugged w/ cerumen --> reflexive cough via Arnold Reflex
c) -allergies --> COUGH and pale, boggy nasal mucosa w/ swollen turbinates
-purulent nasal discharge = sinusitis
d) -pharyngitis --> COUGH and swollen, hyperemic tonsils
-PND --> cough
e) Palpable lymph nodes in neck suggest infxous etiology
f) -Murmurs and gallops = Cardiac Et
-Crackles = Inflammatory Et or worsening CHF
-Dec breath sounds or bronchial breath sounds = pneumonia
-Wheezing = foreign body aspiration, COPD, asthma

6)
a) No w/u as long as cough resolves w/in 6-8 wks
b) ABX w/ f/u to make sure sx resolve
c) d/c ACE I --> improvement of cough in 4 wks
d) Cough w/OUT upper airway abnorm,
who have new cough, persistent cough or hemoptysis
e) Occult bronchospasm;
Allergies;
GERD

7)
a) Cough is a sx. TF "CURATIVE tx" (own description) should focus on correcting the underlying dz process
b) Curative tx and Sx-ic tx
c) Codeine & Dextromethorphan. They act on the medullary cough center
d) 1st gen anti-histamine
Decongestant
e) Guaifenesin. Inc vol and dec viscosity of secretions -->
Easier to clear secretions from respiratory tract

Front 3

Cough Key Points
1) Immunocompetent Pt
+
Persistent Cough
+
Normal CXR
= what 3 possible Dx?

2) PND is a common cause of cough in pts w/ what 2 pt pops?

3) What are 2 centrally acting anti-tussive medications?

Back 3

1) Occult Bronchospasm;
Allergies;
GERD

2) Pts w/ allergies or recent viral URI

3) Codeine;
Dextromethorphan

Front 4

Chest Pain

1) Etiology
a) What are the 6 major categories of chest pain ets?
b) 4 Cardiac causes of CP?
c) 4 Pulmonary causes of CP?
d) 2 Musculoskeletal causes of CP?
e) 4 GI causes of CP?
f) 2 Psychogenic causes of CP?
g) 2 Neurogenic causes of CP?
h) What are the 5 emergent causes of chest pain (most often seen in emergency room and not outpatient setting)?
i) What are the 3 MC categories of chest pain in an office / outpatient setting in order?
k) Which 2 of the above question's answer, MUST ALWAYS be considered in a presentation of chest pain bc of their life-threatening potential?

2) What is the most important / primary concern in pts w/ chest pain?

3) Pathogenesis
a) Muscle chest pain may be the result of inflamm of muscles of chest wall from what 2 things?
b) Costochondritis chest pain may be the result of inflamm of costochondral joints from what 3 things?
c) Obviously rib fx may --> chest pain. Rib fractures often occur as a result of what?
d) Give pathogenesis of cardiac chest pain?
e) What is the major reason why Myocardial O2 demand > Myocardial O2 delivery?
f) CAD is usually the result of formation of atherosclerosis. Give brief pathophys of atherosclerosis? This can lead to what?
g) If calcified plaque ruptures, what can occur?
h) As stated above, their are pulmonary causes of chest pain. However, lung tissue does NOT have pain fibers. TF what is the mechanism / pathophys of chest pain of pulmonary origin?

Back 4

1)
a) Cardiac CP;
Pulmonary CP;
Musculoskeletal CP;
GI CP;
Psychogenic CP;
Neurogenic CP
b) MI, Angina pectoris, Pericarditis, Aortic Dissection
c) PE; Pneumothorax; Pneumonia; Tracheobronchitis
d) Costochondritis; Muscle strain
e) GERD, Esophageal spasm; Cholelithiasis & Cholecystitis
f) Somatization disorders; Anxiety Disorders
g) Herpes zoster; Cervical or Thoracic disc herniation or osteoarthritic narrowing of cervical or thoracic foramen
h) MI; Aortic dissection; PE; Pneumothorax; Unstable Angina
i) Musculoskeletal --> GI --> Cardiac --> Psychogenic and Pulmonary
k) Cardiac and Pulmonary

2) Whether or not the pain is cardiac in origin

3)
a) Overuse & Injury
b) Overuse, injury & viral illness
c) Metastatic CA
d) Myocardial O2 demand > Myocardial O2 delivery?
e) CAD
f) Formation of fatty streak -->
Formation of calcified plaque-->
Narrowed coronary arts -->
Dec Blood flow and O2 delivery to heart
which can lead to angina
g) Thrombus formation and MI
h) Pulmonary ets will cause chest pain via irritation of parietal pleura.

Front 5

4) Chest Pain Hx
a) Apart from your typical COPMAPS questions, you should always ask about what aspect of chest pain?
b) Describe chest pain of cardiac origin (MI, Angina)?
c) Chest pain of cardiac origin (MI, Angina) may have what 4 assoc sx?
d) Describe chest pain of pericardial origin?
e) Chest pain of pericardial origin is usually relieved w/ what?
f) Chest pain of pericardial origin is usually made worse w/ what?
g) Describe the chest pain of aortic dissection?
h) Describe the chest pain of tracheobronchitis?
i) Describe the pain of pneumonia?
j) Describe the pain of pneumothorax?
k) What is pleurisy?
l) Describe the pain of GERD?
m) What makes GERD better? Worse?
n) What type of pain can be reproduced by palpation?

Back 5

4)
a) Pain radiation
b) Substernal chest tightness or pressure that radiates to L. arm, the shoulders &/or the jaw
c) Diaphoresis, SOB, N/V
d) Sharp, severe, persistent
e) Sitting up
f) Breathing, lying back, coughing
g) Ripping or tearing w/ radiation to back or ABD
h) Burning pain in upper sternal area, that is assoc w/ productive cough
i) Pain overlying the chest wall that is aggravated w/ breathing or coughing
j) Sudden onset, sharp, unilateral, pleuritic and assoc w/ SOB
k) a sharp, pleuritic chest pain assoc w/ a viral illness
l) Burning pain that radiates up into the sternum
m) Worse: Large meals and lying down. Better: Antacids.
n) Musculoskeletal pain from costo-chondritis

Front 6

5) Chest Pain PE - WHAT BODY AREAS SHOULD YOU BE CHECKING OUT!?!?!?!?!?
a) Chest Pain + HYPO-TN may = what?
b) Chest pain + Arrhythmia = what?
c) Chest pain + fever = what?
d) Chest pain + rash = what?
e) Chest pain + S4 heart sound = what?
f) Chest pain + S3 heart sound = what?
g) Chest pain + signs of CHF such as pulmonary rales = what?
h) Chest pain assoc w/ pericarditis may have what other 2 PE signs?
i) Beck's Triad consists of what 3 things? Is seen in what?
j) Chest pain resulting from aortic dissection may have what 3 other PE signs?
k) Pts w/ chest pain from pneumonia may have what 3 other PE signs?
l) Pts w/ chest pain from pneumothorax may have what 5 other PE signs?
m) Will pts w/ chest pain from PE have any findings on auscultation?
n) A pt w/ chest pain from PE may have what 3 other PE signs?

Back 6

5)
a) Myocardial ischemia, pericardial tamponade, PE and GI Bleed
b) Cardiac or pulmonary causes of chest pain
c) Infection, ie pneumonia
d) Shingles
e) Myocardial Ischemia
f) Myocardial Ischemia
h) Friction rub and pulsus paridoxicus; Cardiac tamponade.
i) HYPO-TN; No peripheral pulses; murmur of aortic insufficiency
k) Crackles on inspiration, dullness to percussion, egophony
l) Hyperressonance to percussion; tracheal deviation; decreased breath sounds; decreased tactile and vocal fremitus
m) No
n) Tachycardia, Tachypnea, Lower Extremity Edema

Front 7

6) Chest pain Diagnostic Eval & w/u
a) When doing your Hx & PE for a c/c of chest pain, you should try to categorize the pain into what?
b) All pts w/ a complaint of chest pain should get what?
c) Myocardial ischemia and injury are indicated by what on an EKG?
d) Pericarditis will show what on EKG?
e) An old or recent infarct will show what on EKG?
f) What are 3 cardiac enzymes that can be used to help dx chest pain from MI or Myocardial Injury?
g) Which cardiac enzymes are the MOST sensitive and specific?
h) Which cardiac enzymes are the first to rise, and how long do they remain elevated?
i) When does CPK-MB begin to rise and when does it peak?
j) In pts w/ suspected cardiac dz who are stable, what dx-ic test is indicated?
k) Pts w/ baseline EKG abnormalities OR a positive exercise stress test should undergo what test next?
l) What test is useful to detect wall motion abnormalities in areas of the heart damaged by ischemic myocardial dz, pericardial effusions or valvular heart dz?
m) If a pt has pericarditis, but you don't know the cause, what 5 tests should you order?
n) Why would you order a CXR for chest pain?
o) What test(s) would you order if you suspected a PE?

Back 7

6)
a) One of the 6 major categories of chest pain
(Cardiac, Pulm, Musculoskeletal, GI Psychogenic, Neurogenic)
b) EKG
c) ST segment depression and elevation respectively
d) Diffuse ST-segment elevation
e) Q-waves
f) CPK-MB; Troponins, MGB
g) Troponins
h) Troponins; Remain elevated for 5-14 days
i) Begins to rise 4 hrs after MI; Peaks 24 hrs after MI
j) Exercise stress test AFTER having a baseline EKG
k) Radionuclide testing, Stress ECHOcardiogram, and/or Coronary Angiography
l) Echocardiogram
m) ANA, BUN, Creatinine, TSH, Tuberculosis skin test
n) to detect pneumonia, pneumothorax or other LUNG pathology
o) Ventilation / Perfusion scan OR spiral CT + venous Doppler + Possible D-Dimer

Front 8

7) Chest Pain Tx
a) Which pts who have chest pain should be hospitalized?
b) All pts who have chest pain from MI should immediately be stabilized w/ what 4 things?
c) What are 5 other drugs used to tx an acute MI?
d) When should thrombolytics be used to tx MI?
e) What are 8 CIs of thrombolytics?

f) 3 outpt tx for pts w/ stable angina? If these don't work you can add what?

g) According to ATP III guidelines, in pts w/ CAD, what is the goal LDL-C?

h) Tx for aortic dissection?

i) 3 tx for Pericarditis?

j) Tx for PE?

k) Tx for a large pneumothorax?

l) Tx for costochondritis?

Back 8

7)
a) Pts who have chest pain that you suspect results from MI, Unstable angina or PE
b) MONA: Morphine, Oxygen, Nitroglycerin and ASA (Clopidogrel is pt is allergic to ASA)
c) beta-blockers; heparin; nitrates; ACE Inhibs; Thrombolytics
d) In pts w/ MI who are below 75 y/o,
who have ST-seg elevation,
a hx consistent w/ acute MI,
who present w/in 6 hrs of onset of pain
e) Active internal bleed,
Hx of CVD,
Recent surgery,
Intracranial neoplasm,
AVM,
Aneurysm,
Bleeding diathesis,
Severe uncontrolled HTN

f) ASA, SL Nitroglycerin, beta-blockers. Add Ca-Chann blockers!
g) < 100 (although newer evidence suggests < 75)

h) Hospitalization and surgical consult

i) ASA, other NSAIDs, or Steroids in severe cases

j) anti-coags Warfarin + Heparin concomittantly

k) Chest tube insertion

l) NSAIDs

Front 9

Chest Pain Key Points: READ P. 38

Back 9

Chest Pain Key Points: READ P. 38

Front 10

Dyspnea

Back 10

Dyspnea

Front 11

1) Define dyspnea

2) Et of Dyspnea
a) What are the 2 major categories of dyspnea?

3) Et of Dyspnea cont'd
a) List 9 acute causes of dyspnea?
b) List 12 chronic causes of dyspnea?

c) What 2 general categories acct for the majority of pts w/ dyspnea?
d) What are the 4 MC Cardiopulmonary causes of dyspnea?

e) What are 5 causes of dyspnea that are MC'ly seen in peds?

Back 11

1) SOB; a sensation of difficult or uncomfortable breathing

2)
a) Acute Dyspnea
b) Chronic Dyspnea

3)
a) Acute anxiety attack / panic disorder;
Anemia;
Bronchospasm;
MI;
Pneumonia;
Pneumothorax;
PE;
Pulmonary Edema;
Upper airway obstruction

b) Anemia;
Anxiety;
Ascites;
Asthma;
COPD;
Congestive Heart Failure;
Interstitial Lung Dz;
Lyphoscoliosis;
Lung Mass;
Obesity;
Pleural Effusion;
Pulmonary HTN

c) Anxiety; Cardiopulmonary
d) Asthma, COPD, Pneumonia, CHF

e) Foreign body aspiration;
Upper airway obstruction;
Asthma;
Pneumonia;
Bronchiolitis

Front 12

4) Pathogenesis of Dyspnea
a) Give the general pathogenesis of dyspnea?
b) For example, w/ pneumonia or a PE ______

5) Hx of Dyspnea - some common scenarios
a) Dyspnea + Substernal chest pressure = what?
b) Dyspnea + Swollen leg = what?
c) Dyspnea + Melena or Dysfnctnl Uterine Bleeding = what?
d) Dyspnea + stress / perioral numbness / paresthesias = what?

6) PE of Dyspnea
a) The PE of dyspnea should focus on what body areas?
b) During the heart exam you should note what 2 things in search of arrhythmias?
c) During the heart exam you may notice _____ resulting from an MI (Acute dyspnea). In particular, you may notice _______ resulting from MI (acute dyspnea), which may lead to dyspnea.
d) What 2 PE signs may indicate that dyspnea is resulting from CHF (Chronic Dyspnea)?
e) Peripheral edema that is noted on PE may indicate that what may be contributing to the pt's sx?

f) What 3 things should you look for when starting the lung examination?
g) Increased respiratory effort is demonstrated how?
h) When examining chest and ABD contours, what are 3 things you should look for in particular?

i) Why should you percuss the lungs in a pt c/o dyspnea?
j) 4 reasons to auscultate the lungs?

Back 12

4)
a) Dyspnea occurs when
The body's perceived need for O2 is not being met OR
When the work of breathing increases
b) w/ pneumonia or a PE the lungs' ability to provide sufficient O2 to the peripheral and central chemoreceptors is decreased -->
Sensation of dyspnea

5)
a) Angina
b) PE
c) Anemia
d) Anxiety

6)
a) Heart & Lungs
b) Rate & Rhythm
c) Arrhythmias; a-fib
d) Murmurs, S3 heart sound
e) Peripheral edema

f) Respiratory rate, Respiratory effort, Chest & ABD contours
g) Use of accessory muscles
h) Barrel chest of COPD; Ascites for liver probs

i) Assess for pleural effusion
j) Presence of rales, wheezing, rubs or diminished breath sounds

Front 13

8) Diagnostic Eval & w/u
a) What are 2 critical initial factors you must determine when evaluating a pt w/ dyspnea?
b) What is one instrument available in most offices that can help assess a pts cond'n?

c) What imaging should be obtained in most pts w/ a c/o dyspnea?
d) A CXR that shows infiltrates = what?
e) CXR that shows hyperinfiltration = what?
f) CXR that shows pulmonary edema = what?
g) CXR w/ a honeycomb appearance what?
***NOTE: CXR can also show pleural effusion, pneumothorax, lung mass, interstitial lung markings***

h) If you suspect that lung dz is the cause of the dyspnea, what may be helpful in diagnosing obstructive or restrictive lung dz?
i) If you suspect that lung dz is the cause of the dyspnea, what may be used to document respiratory status?

j) What is 1 tool that can be used to assess cardiac status?
k) What is another tool that can be used to asses cardiac status?

l) What tool can be used to detect exercise-induced asthma?

Back 13

8)
a) Severity of the dyspnea; Whether the pt requires immediate intervention
b) PulsOx

c) CXR
d) Pneumonia
e) Obstructive lung dz
f) CHF
g) Interstitial Lung Dz
***NOTE: CXR can also show pleural effusion, pneumothorax, lung mass, interstitial lung markings***

h) PFTs
i) ABGs

j) EKG can be used to asses angina, or MI --> arrhythmia
k) Echocardiogram can be used to assess systolic &/or diastolic dysfnctn -->
pulmonary congestion and CHF

l) Exercise stress testing

Front 14

9) Diagnostic Eval & w/u cont'd
a) Why should you get a CBC on a pt w/ anemia?
b) An elevated WBC may indicate that the underlying cause of the dyspnea is what?
c) Why look @ the HGB in a pt w/ dyspnea?

d) In an acute setting, what lab value may be useful in differentiating b/t CHF & a pulmonary cause of dyspnea?
e) What is BNP?
f) How can BNP differentiate b/t CHF & a pulmonary cause of dyspnea?

g) In a pt w/ episodic sx and a normal cardiopulmonary evaluation, what should be considered?

h) What should you consider last in your w/u of dyspnea?


10) Tx of Dyspnea
a) The most important thing to remember when treating dyspnea is that you need to tx what?

b) Tx for pt w/ PE?
c) Tx for pneumonia?
d) Bronschospasm?
e) Acute tx for CHF?

Back 14

9)
a) WBC count & HGB
b) Infectious (ie: pneumonia)
c) To check for anemia

d) BNP (Brain Natriuretic Peptide)
e) A hormone originating from the ventricles
f) BNP will be elevated in CHF. BNP will NOT be elevated in a pulmonary cause of dyspnea.

g) GERD w/ secondary bronchospasm

h) Psychiatric etiologies such as anxiety and panic disorder

10)
a) The underlying cause

b) Hospitalization and Anti-coagulation
c) ABX
d) Bronchodilators
e) Diuretics

Front 15

Dyspnea Key Points

1) The MCCes of dyspnea are cardiopulmonary

2) Most pts w/ dyspnea should have a CXR

3) Other causes of dyspnea include anemia, anxiety, obesity, ascites, kyphoscoliosis

4) Common causes of dyspnea in peds includes Asthma and Respiratory Tract Infections (pneumonia and bronchiolitis)

Back 15

Dyspnea Key Points

1) The MCCes of dyspnea are cardiopulmonary

2) Most pts w/ dyspnea should have a CXR

3) Other causes of dyspnea include anemia, anxiety, obesity, ascites, kyphoscoliosis

4) Common causes of dyspnea in peds includes Asthma and Respiratory Tract Infections (pneumonia and bronchiolitis)

Front 16

Swelling / Edema

1) Edema is another name for what?

2) Leg edema is frequently associated w/ what 2 other dz'es / cond'ns?

3) Et of Swelling / Edema
***SEE Box 32-1 (p. 109) for all causes of edema / swelling***
a) You can split the etiologies of edema into 3 different groups, based on the type of edema they cause. What are those 3 groups?
b) What are the 5 MCC of Generalized Edema?
c) In the family practice setting, what is the MCC of BL Leg edema?
d) What are the 2 major causes of regional edema?
***Note, their are many causes of venous obstruction listed under the ddx on p. 108***

4) Hx of Edema / Swelling
a) What are 5 common s/s of edema?
b) Edema assoc w/ pulmonary edema may have what 3 sx?
c) What are 4 medications that can cause fluid retention?
d) Which of the above medications causes facial edema in particular?
e) What hx suggests a dx of idiopathic cyclic edema?

Back 16

1) Swelling

2) CHF, Renal failure

3)
a) BL Leg / Generalized edema;
Acute UL leg edema;
Chronic UL Leg edema
b) Hypoalbuminemia, Cirrhosis;
Nephritic syndrome, Renal insufficiency;
CHF
c) Chronic venous insufficiency
d) Venous insufficiency or Venous obstruction -->
Inc capillary hydrostatic pressure

4)
a) Leg swelling;
Wt gain;
Shoe & clothing tightness;
Puffiness of the eyes and face;
Inc ABD girth
b) Exertional dyspnea;
Orthopnea (SOB that occurs when lying flat);
Paroxysmal Nocturnal Dyspnea
c) NSAIDs;
Vasodilators Nifedipine & Prazosin;
ACE I
d) ACE I
e) Hx of diurnal variations of 4-5 lbs / day in a healthy young woman

Front 17

5) Edema PE
a) What is one of the cardinal PES of edema?
b) Generalized edema usually suggests what 2 etiologies?

c) The PE for edema should focus on what 3/4 areas?

d) Neck vein distention + Peripheral edema + Rales = what?

e) Edema + what 3 s/s = cirrhosis?
f) What s/s indicate edema resulting from lymphatic obstruction?
g) Chronic venous insufficiency can lead to leg edema and what other 2 s/s on PE?

h) On PE of edema, you should always do what?
i) Nonpitting leg edema may be a sign of what?
j) Nonpitting localized edema may be a sign of what?

Back 17

5)
a) Rapid wt gain over a short period of time
b) Renal or hepatic dz

c) cardiopulmonary;
ABD;
Pelvic Exams

d) CHF or pulmonary HTN

e) Palmar erythema; spider telangiectasias, Ascites
f) Prostatic mass, Pelvic mass, Inguinal adenopathy
g) Stasis dermatitis and venous varicosities

h) Check for pitting
i) Hypothyroidism
j) Lymphedema

Front 18

6) Diagnostic Eval & w/u
a) In a pt w/ generalized edema, what are the routine lab tests that you should order?
b) What does the chemistry panel assess?
c) What does the UA provide information about?\
***In what 2 dz states would you see Hypoalbuminemia?
d) What does the CXR provide information about?

e) Why might you order a TSH in someone w/ edema?
f) If a pt has CHF and edema, what 2 tests should you order to assess heart fnctn?

g) If a pt has unilateral leg edema, you should r/o what?
h) What test do you order to r/o DVT?

i) If you suspect edema resulting from mass or obstruction, what test should you order?

Back 18

6)
a) Chemistry panel; CBC; UA; CXR
b) Renal fnctn, albumin levels, electrolytes
c) The presence of renal dz by looking for nephrotic range proteinuria
***Malnutrition or Liver Dz
d) Pulmonary congestion, pulmonary effusions, heart size, pericardial dz

e) To r/o myxedema (hypothyroidism) as a cause of edema
f) EKG and Echo

g) DVT
h) US

i) CT of ABD & Pelvis

Front 19

7) Tx of Edema
a) BC their are many causes of edema, you must tx what?
b) If their is edema from nephrotic syndrome, what should you prescribe?
c) If their is edema from CHF, what should you prescribe?
*Which of the above should be used cautiously and only as an adjunct to non-pharmacological tx?
**Edema of what 2 etiologies usually does NOT respond to diuretics?

d) What are 3 non-pharmacologic measures you can use for edema?
e) Compression stockings are CI in who?

Back 19

7)
a) Underlying cause
b) Corticosteroids
c) Diuretics and ACE Inhibitors
*Diuretics
**Lymphedema, Edema from Chronic venous insufficiency
d) Leg elevation, Compression stockings, salt restriction
e) pts w/ arterial insufficiency

Front 20

Edema Key Points

1) The importance of leg edema is bc of its requent association w/ what 2 illness?

2) Generalized edema is USUALLY the result of what 4 probs?

3) What are 3 useful non-pharmacologic measures for treating edema?

4) What are 2 types of edema for which diuretics DO NOT work?

Back 20

1) CHF or Renal failure

2) Hypoalbuminemia, cardiac, renal or hepatic dz

3) Leg elevation, compression stockings, salt restriction

4) Lymphedema;
Chronic venous insufficiency

Front 21

Allergies

***NOTE: The term "Allergy" could mean 1 of 4 different types of "Hypersensitivities."
BUT, when we use the term "Allergy," it usually means a Type I IgE mediated Hypersensitivity

Back 21

Allergies

Front 22

1) What is the definition of an "allergy?"

2) What is the definition of atopy?

Back 22

1) An IgE-mediated, Type I hypersensitivity -->
Allergic rhinitis;
Atopic dermatitis;
Conjunctivitis;
Asthma;
Food allergies;
Systemic anaphylaxis

2) A GENETIC PREDISPOSITION to form IgE Ab and subsequent TI HS RXNs in response to exposure to allergens

Front 23

More than 1/2 of the cases of asthma in the United States can be attributed to what?

Back 23

Seasonal allergies

Front 24

Pathogenesis of Allergies
(Remember, all "Allergies" are TI HS)

1) Describe the pathogenesis of allergic rhinitis?

2) Now remember, Asthma is also a TI HS ("Allergy"). What are 3 allergens that can trigger the TI HS of asthma?

3) Will exposure to an allergen to which a person is sensitized ALWAYS lead to systemic, generalized sx?

4) What are 2 common skin manifestations of allergies?

5) 4 GI sx of allergen exposure?

6) What are 8 common food allergies in kids?

7) What are 4 common food allergies in adults?

Back 24

1) Person becomes sensitized to an allergen (p.27 gives common allergens based on time of year):
Exposure to allergen -->
IgE on Mast Cells

IN NASAL MUCOSA:
Re-exposure to Allergen + IgE on Mast Cells -->
Mast Cell degranulation -->
Release of Histamine, LT, Bradykinin -->
Vasodilation, Fluid Transudation and Swelling -->
Rhinitis

2) Air pollution, dust mites, cockroaches

3) No. Exposure to an allergen may only produce cutaneous, Respiratory or GI sx

4) Urticaria & Eczema

5) n/v/d and ABD pain

6) milk, egg, peanuts, soy, wheat, tree nuts, fish and shellfish

7) peanuts, tree nuts, fish and shellfish

Front 25

Allergies Pathogenesis Cont'd
8) Anaphylaxis
a) What is anaphylaxis?
b) What are 7 sx of anaphylaxis?
c) Why is it crucial that pts experiencing anaphylaxis receive immediate emergency care?

Back 25

8)
a) A severe, life-threatening systemic allergic rxn that can result from
exposure to a food allergen,
blood transfusion,
medication,
insect stings (bees, etc..)
b) Agitation;
Palpitations;
Paresthesias;
Pruritus;
Difficulty swallowing;
Cough;
Wheezing
c) BC the sx may progress rapidly -->
Cardiovascular Collapse

Front 26

Allergies Hx

1) What are some general sx of allergies?

2) Allergic Rhinitis
a) What are the sx of allergic rhinitis?

3) Food allergies
a) Food allergies often effect what 2 body systems?
b) What is 1 skin manifestation of food allergies?

4) Diff Allergens
a) What allergens tend to affect ppl more in the early spring?
b) What allergens tend to effect ppl from mid-May to June?
c) What allergens tend to effect ppl from August until the first frost?
d) Worse allergy sx during the day suggests what type of allergen is responsible?
e) What allergens are perennial (year round)?
f) Allergy sx that are worse during the night suggest what type of allergens?

Back 26

1) Nonproductive cough;
Nasal congestion w/ HA;
Plugged and itchy ears;
Dec smell and taste;
Sleep disturbances

2)
a) Nasal Congestion;
Rhinorrhea;
Sneezing;
Conjunctivitis;
Itchy eyes, ears, nose and throat

3)
a) Skin & GI system
b) Urticaria

4)
a) Tree pollens
b) Grasses
c) Ragweed
d) Pollens
e) House dust;
Feathers;
Animal Dander;
Molds
f) The perennial allergens above

Front 27

Allergies PE

1) The PE for allergies should focus on what body areas?

2) What are 2 eye s/s in pts w/ allergies?

3) 3 nose s/s in pts w/ allergies?
a) 1 sinuses s/s in pts w/ allergies?

4) What is 1 eye finding in pts w/ allergies?

5) 1 lung finding in pts w/ allergies?

6) Skin Rxns w/ allergies
a) What are 2 types of skin rxns often seen in kids w/ food allergies?
b) Atopic dermatitis in infants and young kids usually presents how?
c) Atopic dermatitis in pre-school and school children usually presents how?
d) Describe atopic dermatitis in adults?

Back 27

1) Eyes, Nose w/ sinuses, Throat, Lungs and Skin

2) Conjunctivitis and Increased Lacrimation

3) Pale and swollen nasal mucosa;
Nasal polyps on the turbinates;
Crease across bridge of nose from "allergic salute"
a) Tender sinuses

4) "Allergic Shiners":
Darkening of infraorbital skin in ppl w/ chronic allergies

5) Wheezing

6)
a) Eczema and Urticaria
b) Exudative eruption w/ oozing and crusting in the head, neck, forearms, wrists and diaper area
c) Dry and scaly rash
d) Eczematous rash that is flat, erythematous, pruritic and svaly

Front 28

Allergies DDx

1) Conjunctivitis
a) When a pt presents w/ conjunctivitis that you suspect is allergic in origin, what other causes of conjunctivitis must you r/o?

2) Rhinorrhea
a) Although Rhinorrhea may be due to allergies, what are other causes that you must consider?
b) Give one way to differentiate b/t rhinitis from the common cold and rhinitis from an allergy?
c) Rhinitis from what etiology will include nasal pruritus?
d) Vasomotor rhinitis will present how?

e) Atrophic Rhinitis
-Atrophic Rhinitis have what 4 characteristics?

f) What is Rhinitis medicamentosa?

g) Rhinitis may also be caused by sinusitis. Give some s/s of sinusitis?

3) Nasal congestion may have hormonal causes. Give 3 hormonal causes of nasal congestion?

Back 28

1)
a) Viral, bacterial and irritant

2)
a) Common cold;
Vasomotor rhiniits;
Atrophic rhinitis;
Rhinitis medicamentosa;
Rhinitis from sinusitis
b) Rhinitis from a common cold will present w/ a nasal mucosa that is Red w/ thickened discharge;
Rhinitis from allergies will present w/ a nasal mucosa that is pale, boggy and/or bluish
c) Allergic rhinitis
d) Chronic nasal congestion and Watery rhinorrhea

e)
-Seen in elderly;
Marked atrophy of nasal mucosa;
Chronic nasal congestion;
Bad odor

f) Rhinitis resulting from chronic use of cocaine or topical nasal decongestants

g) Purulent nasal discharge;
HA;
Nasal congestion;
Facial pain;
Tenderness over sinuses

3) Pregnancy;
Birth CTL pills;
Hypothyroidism

Front 29

Dx Eval and w/u

1) In most pts, the dx of some sort of allergic dz is usually made how?
a) TF, in most pts, after a dx of allergic dz is made based on H&P, what is the next best step?
b) If pts don't respond to this empiric tx, what is the next best step?
c) What are 2 diff types of allergy testing?
d) How does the RAST work?
e) How does skin-prick testing work?

f) What is the next step if allergy testing does not reveal any allergens?

2) Sometimes in pts w/ allergic rhinitis, nasal smears may be ordered. What can be found on microscopic examination that is characteristic of allergic rhinitis?

3) How are food allergies dx'ed?

Back 29

1) By Hx and PE
a) Empiric Tx -
it can be started WITHOUT any dx-ic tests-
If the pt responds to tx, no further dx-ic testing is needed
b) Allergy testing
c) RAST (Radioallergosorbent Test) & Skin-prick testing
d) The RAST tests the blood for the presence of IgE to different allergens
e) Injecting a small amt of allergen into the skin and observing for a local response

f) Flexible nasolaryngoscopy to r/o any anatomic or pathologic abnormalities

2) Eosinophils

3) Avoidance and Challenge testing

Front 30

Allergies Tx

1) What is the 1st-line tx for any allergic disorder?

2) What are 5 pharmacological options for allergies?

3) Allergic Rhinitis
a) First line Tx for Allergic Rhinitis? MOA?
b) If pt has mild-to-severe persistent allergic rhinitis, what is the tx of choice?

4) Nasal Congestion
a) 1 tx for nasal congestion? AEs / CIs?

5) 2 Tx for allergic conjunctivitis?

6) What may be used to help dec allergy sx in pts w/ allergic sx who also have concomittant asthma?

7) How to tx skin manifestations of allergies?
a) What can be used TEMPORARILY for acute urticaria?

8) Tx of choice for anaphylaxis?

9) Immunotherapy (allergy shots) is one tx option. What is immunotherapy?

10) General / All Allergies
a) What type of medication(s) are very potent BUT can have serious LT SE and TF should be limited to 3-7 days.
b) Cromolyn is available as an OTC nasal spray. What is the MOA of Cromolyn?
c) Often, but not always, what is the 1st line tx for children and pregnant women?

Back 30

1) Avoidance

2) Antihistamines;
Corticosteroids (Oral and Intranasal);
Cromolyn Sodium (Intranasal);
Decongestants (Oral and Topical);
LTRA (Leukotriene Receptor Antag)

3)
a) Anti-histamines;
Block H1 receptors -->
Dec Histamine release -->
Dec sneezing, rhinorrhea and itching
b) Intranasal steroids

4)
a) Oral decongestants like pseudoephedrine;
CI'ed in HTN, Thyroid dz, Diabetes, Difficult Urination

5) Topical Tx;
Oral anti-histamines

6) LTRA

7) Oral anti-histamines;
Topical steroids;
Cool Colloid Baths
a) Oral steroids

8) Epinephrine

9) When pts are exposed to increasing concentrations allergens via Sub-Q injections -->
Tolerance to a specific allergen

10)
a) Oral corticosteroids
b) Mast-cell stabilizer (prevents mast cell degranulation)
c) Cromolyn

Front 31

Allergies Key Points

1) Type I HS RXNs are mediated by Ag binding to what on MC and Basophils?
a) This then leads to what?

2) What is the Tx of Choice for moderate-to-severe persistent allergic rhinitis?

3) What is the FIRST and DEFINITIVE Tx for any allergic disorder?

Back 31

1) IgE
a) Mast cell degranulation

2) Intranasal steroids

3) Avoidance of the offending allergen

Front 32

NOTE:
SEE P.29 FOR ALGORHYTHM OF ALLERGIC RHINITIS TX

Back 32

NOTE:
SEE P.29 FOR ALGORHYTHM OF ALLERGIC RHINITIS TX

Front 33

Respiratory Infxns

Back 33

Respiratory Infxns

Front 34

1) Their are 2 different types of respiratory infxns, URIs and LRIs. What is the difference b/t URIs and LRIs?

2) What are 4 types of URIs? Most URIs are caused by what?
a) What are the 2 MCCs of common cold?
b) Laryngitis is almost always (90% of the time) caused by what? Which ones in particular?

3) What are 2 types of LRIs?
a) Define bronchitis?
b) 95% of bronchitis is caused by what?
c) The other 5% are mostly attributable to what 3 things?

d) What is the definition of pneumonia?

Back 34

1) URIs: Infxns of the trachea and above
LRIs: Infxns of the trachea, bronchi and pulmonary structures

2) Common Cold, Sinusitis, Pharyngitis, Laryngitis;
Viruses
a) Rhinovirus & Coronavirus
b) Viruses;
Influenza, Parainfluenza, Rhinovirus, Adenovirus

3) Bronchitis, Pneumonia
a) Inflammation of the lining of the bronchial tubes
b) viruses
c) chemical irritation of the lining of the bronchial tubes,
Mycoplasma infxn,
Chlamydia infxn

d) Inflammation of the terminal airways, alveoli and lung interstitium (usually resulting from infxn!!!)

Front 35

Respiratory Infxns Pathogenesis

1) What is the pathogenesis of URIs?
a) Give the pathogenesis of sinusitis (a type of URI)?
b) Give pathogenesis of an acute exacerbation of chronic bronchitis?
c) Give the pathogenesis of pneumonia?
d) What are the 4 MCC of CAP in an otherwise healthy person?
e) What are 4 common causes of pneumonia in an HIV (I/C) person?

Back 35

1) Since URIs are mostly caused by viruses, these viruses replicate in the nasopharynx -->
Inflammation, Edema, Erythema and Nasal Discharge
a) Inflammation and swelling of the mucous membranes of the sinuses -->
blockage of ostia draining the sinuses -->
Mucous pooling and bacterial proliferation and infxn of the sinuses

OR

Anatomical obstruction of the ostia of the sinuses (from things like polyps)--> blockage of ostia draining the sinuses -->
Mucous pooling and bacterial proliferation and infxn of the sinuses

OR

Dental Abscess -> ~~~

b) Usually viral infxn, but sometimes bacterial colonization of the airway -->
acute exacerbation of chronic bronchitis

c) Aspiration of oropharyngeal (although sometimes gastric) secretions that are colonized by pathogens.
d) S. pneumo, H. flu, Mycoplasma pneumoniae, C. pneumoniae
e) Fungus, PCP, CMV, MTB

Front 36

Respiratory Infxns Hx

1) Cold (URI)
a) List some sx of a cold?
b) When do the acute sx of a cold usually resolve? How long until the cough associated w/ a cold will resolve?

2) Sinusitis (URI)
a) Give 3 sx of sinusitis that can be elicited in the pts hx?

3) Acute Bronchitis (LRI)
a) 4 sx of Acute Bronchitis that can be elicited in the pts hx?

4) Pneumonia (LRI)
a) What are the sx of pneumonia that can be elicited in the pts hx?

Back 36

1)
a) Scratchy sore throat,
Sneezing,
Nasal congestion,
Rhinorrhea,
Malaise,
Fever,
Hoarseness,
Cough,
Low grade fever,
HA
b) 1 wk for acute sx,
Several wks for cough

2)
a) Purulent nasal discharge,
Facial pain exacerbated by leaning forward,
Maxillary toothache

3)
a) Productive cough,
Low Grade Fever,
Fatigue,
Sometimes URI Sx

4) Pneumonia (LRI)
a) Same as bronchitis EXCEPT pneumonia pts will often also have:
Fever, Chills, SOB, Chest pain

Front 37

Respiratory Infxns PE

1) What body areas need to be examined in a suspected respiratory infxn?

2) Nose
a) Describe the nasal mucosa of someone w/ a URI?

3) Sinusitis
a) What PE signs suggest sinusitis?

4) Bronchitis
a) Describe the auscultation of someone w/ bronchitis?

5) Pneumonia
a) We already said that pts w/ pneumonia will often have the sam hx as bronchitis EXCEPT pneumonia pts will often also have:
Fever, Chills, SOB, Chest pain.
What 3 non-auscultory PE signs will pts w/ pneumonia also have?
b) What auscultory PE signs will pts w/ pneumonia often have?
c) What will you hear on percussion for pts w/ pneumonia?

Back 37

1) ENT,
Sinuses,
Neck,
Cardiac,
Pulmonary

2)
a) Red & Swollen

3)
a) Purulent nasal discharge,
facial tenderness,
loss of maxillary transillumination

4)
a) Usually clear lungs,
but possibly rhonchi, hoarse rales or wheezing

5)
a) Fever, Tachypnea, Tachycardia, and look more ill
b) Rales, Bronchial breath sounds, wheezing
c) Dullness to percussion

Front 38

Respiratory Infxns DDx

1) Sinusitis
Apart from sinusitis, what is the DDx of acute sinus pain?

2) Differentiating Bronchitis from Pneumonia
a) CXR?
b) Auscultation?
c) Fever?
d) Chest pain?
e) Leukocytosis

Back 38

1)
a) Dental dz,
Nasal foreign body,
Migraine,
Cluster HA

2)
a) Bronchitis: Normal
Pneumonia: Pulmonary Infiltrate
b) Bronchitis: Usually clear lungs, but possibly rhonchi, hoarse rales or wheezing
Pneumonia: Rales, Bronchial breath sounds, Wheezing
c) Bronchitis: Not usually
Pneumonia: Usually
d) Bronchitis: Not usually
Pneumonia: yes
e) Bronchitis: No
Pneumonia: Yes

Front 39

Respiratory Infxns Dx-ic Eval & w/u

1) URIs
a) Most pts w/ URIs are dx'ed how?
b) Is blood testing or imaging necesarry for acute sinusitis?
c) If a pt does have a complication of sinusitis, or has chronic sinusitis, what imaging procedure of choice is indicated?

2) LRIs
a) If after PE pneumonia is suspected, what is the next best step?
b) What 4 things will a CXR be able to tell you?
c) What are 7 lab tests you should order when you w/u a suspected pneumonia?

Back 39

1)
a) Clinically
b) Not unless they appear toxic of have complications of sinusiits, such as:
orbital cellulitis,
cavernous thrombosis
c) CT

2)
a) CXR
b) Distinguish b/t bronchitis & pneumonia;
assess the extent of the dz;
detect pleural effusions;
distinguish b/t infectious and non-infectious causes
c) CBC, lytes, BUN, Cr, Pulsox, Sputum for gram stain and culture, LFTs

Front 40

Tx URI

1) What 3/4 tx are indicated in to relieve URI sx of pain and fever?

2) Nasal congestion
a) What can be used to relieve nasal congestion?
b) ) What is one risk in using topical decongestants (phenylephrine) for nasal congestion?

3) Rhinnorhea
a) Give one anti-cholinergic agent that can be used for Rhinorrhea?

4) Sinusitis
a) What are the 2 goals of tx-ing sinusitis?
b) 6 non-pharm tx for sinusitis?
c) Give one mucolytic that may be helpful in tx-ing sinusitis?

d) What is the next best step if sinusitis sx persist for more than 1 wk?
e) What 2 ABX are best for initial ABX tx of sinusitis?
f) What if pts are allergic to the above medications?

Back 40

1) Fluids, rest, NSAIDs or Acetominophen

2)
a) Sympathomimetics such as pseudoephedrine
b) Rebound congestion

3)
a) Ipratropium bromide

4)
a) Improving Drainage and eradicating pathogens
b) Decongestants, Hydration, Analgesics, Warm facial packs, humidification and sleeping w/ head elevated
c) Guaifenesin

d) Abx for 10-14 days
e) Amoxicillin, TMP/SMX
f) Give Cephalosporins, Macrolides, Quinolones

Front 41

Tx URI

1) Bronchitis
a) What are 4 non-pharm tx for bronchitis?

2) Pneumonia Tx
*NOTE: In a hospital setting, sputum gram stain and sensitivity should guide choice of ABX. But for the following, we'll consider the best empiric outpt tx
a) What are 3 ABX tx options for healthy adults less than 60 y/o?
b) What are 3 ABX tx options for pts > 60 y/o?
c) Since kids 2 mos - 5 yrs are unlikely to be infected w/ an atypical pathogen, what is the recommended outpt tx for them?
d) Older children should be given what ABX for their pneumonia and why?

Back 41

1)
a) Fluids, Decongestants, Smoking Cessation, Cough suppressants

2)
a) Erythromycin,
Extended-Spec Macrolide (Azithromycin),
Doxycycline
b) Fluoroquinolone w/ activity against pneumococcus (Levofloxacin),
a new Macrolide,
2nd Generation cephalosporin
c) High dose Amoxicillin for 7-10 days
d) Macrolide;
bc of increased incidence of Mycoplasma pneumoniae and C. pneumoniae in older children

Front 42

Respiratory Infxns Key Points

1) What are the 4 common organisms causing CAP in otherwise healthy adults?

2) Blood tests or imaging is not req'd for pts w/ acute sinusitis unless what?

Back 42

1) S. pnemo, H. flu, M. pneumoniae, Chlamydia pneumoniae

2) Unless they appear toxic or have a complicatio of sinusitis such as:
orbital cellulitis or cavernous thrombosis

Front 43

HTN

Back 43

HTN

Front 44

1) What is the definition of HTN?

2) What is White Coat HTN?

3) What is pseudo-HTN?

4) Give the stages of HTN?

Back 44

1)
SBP > or = 140
DBP > or = 90
On 2 consecutive visits, 2 wks apart

OR

1 SBP > or = 210

OR

1 DBP > or = 120


2) When the pt's BP is elevated in the doctor's office, but not any other time

3) When the pt is elderly and has calcified, rigid blood vessels -->
Intra-arterial BP that is actually lower than what is measured by the BP cuff

4) Optimal: < 120/80
Pre-HTN: 120-139 / 80-89
Stage 1: 140-159 / 90-99
Stage 2: > or = 160 / > or = 100

Front 45

Pathogenesis of HTN

1) Primary (Essential) HTN accts for how much of the HTN in the population?

2) Secondary HTN accts for how much of the HTN in the population?
a) Give some of the major causes of secondary HTN?
b) Give the mechanism by which Hyperinsulinemia can cause HTN?

Back 45

1) 90-95%

2) 5-10% of all adult HTN
a) Exogenous substances (Stimulants, ETHOL, Drugs);
Renal failure, renovascular dz, sleep apnea, primary aldosteronism, pheochromocytoma, Cushing's Syndrome, Hyperinsulinemia
b) -Hyperinsulinemia increases vascular tone by:
*Stim Na retention
*Stim vascular hypertrophy and hyperplasia
*Causing increased IC Ca
*Stim Symp NS

Front 46

HTN Hx
1) Now remember, that HTN is usually asx-ic until their is end-organ damage. Give some of the major clinical manifestations of end-organ damage of HTN AND the questions you should ask in your hx to assess this end-organ damage?
a) What additional questions should you ask about in your hx?
b) Name 6 drugs you should ask about that may cause HTN?

***NOTE: Their is a list of questions you should ask that suggest a secondary cause of HTN on p. 155

Back 46

1) Ischemic Heart Dz (Chest Pain?, SOB?);
Stroke (Prior TIAs?);
Peripheral vascular dz;
Renal insufficiency;
Retinopathy characterized by exudates or hemorrhages;
Papilledema
a) Family hx of heart dz, HTN, Hyperlipidemia, DM, Renal dz;
Smoking and Alcohol;
Diet & Exercise;
Medications
b) NSAIDs,
Decongestants,
Estrogen,
Progesterone,
Appetite suppressants,
MAOIs

Front 47

HTN PE

1) What aspects of the PE should be performed to check for end-organ damage?

2) What aspects of the PE should be performed to check for a secondary cause?

Back 47

1) Skin exam for PVD;
Funduscopic exam for retinal hemorrhages, increased vascular tortuosity, AV nicking;
Auscultate carotids for bruit;
Auscultate ABD for bruits

2) Signs of Cushings;
Signs of Neurofibromatosis;
Thyroid for enlargement or nodularity;
Auscultate lungs for signs of heart failure;
Exam ABD for masses

Front 48

DX-ic Eval & w/u of HTN

1) Once the dx of HTN has been made, what 4 questions need to be asked?

2) Why might you get a
CBC on a pt w/ HTN?
a) Why might you get a serum Ca and Uric Acid on a pt w/ HTN?

3) For newly dx'ed HTN pts, what labs should be ordered?
a) Why would you order the above labs?

Back 48

1)
1. Primary or Secondary?
2. What risk factors are present?
3. Evidence of end organ damage?
4. Are any comorbid cond'ns present that would affect your choice of tx?

2) As a baseline in case their is any medication induced neutropenia or agranulocytosis
a) To r/o hyper-parathyroidism (Ca)
AND
BC Inc Serum Ca and Uric Acid may preclude the use of thiazide diuretics

3) Fasting glucose;
K+;
Cr;
UA;
Lipid Panel

a) Fasting Glucose: DM
Hypokelamia: Hyperaldosteronism
Inc Cr: Renal Insuffiicency
Proteinuria and Microalbuminuria on UA: Renal Damage

Front 49

HTN Tx

1) What is the therapeutic goal for all pts?

2) Tx of Non-Diabetic pts w/ Normal Renal Fnctn
a) DB, NRF pt w/ Pre-HTN. 1st steo?

3) Isolated Systolic HTN (SBP > or = 140, commonly seen in elderly)?
a)

Back 49

1) < or = 120/80

2)
a) Lifestyle Mods including salt reduction, dec ETHOL, wt loss, aerobic exercise

3)
a) Low dose diuretics and beta blockers

Front 50

HTN Tx Cont'd

1) What are the 5 classes of drugs most often used as 1st line agents for HTN?

2) Diuretics
a) Thiazides are especially useful in what pt population?
b) What diuretic is best for pts w/ renal impairment?
c) What drugs interfere w/ the delivery of loop diuretics to their site of action?
d) Give the FX of Thiazide and Loop Diuretics on Ca levels?

3) BB
a) What are the 4 ways that BB act to decrease BP?
b) What are the 2 low renin states and why does it make sense that BB might not be as helpful for these ppl?
c) Why must you be careful in giving BB to asthmatics?

4) ACE I
a) What 2 pt populations will particularly benefit from ACE I?
b) How are ACE I renal-protective?
c) MC SE of ACE I is what?

5) ARBs
a) What is 1 advantage and 2 disadvantages to using ARBs instead of ACE I

6) CCB
a) Give 3 Ca Channel Blockers?
b) 1 way that ALL CCB work?
c) Dilitiazem and verapamil have what 2 additional MOA?

***NOTE: other 2nd line medications are given on p 158 under "Other Hypertensive Medications"

Back 50

1) ACE I;
ARBs;
BB;
CCB;
Diuretics

2)
a) Pts WITHOUT renal impariment
b) Loop diuretics (furosemide)
c) NSAIDs
d) Loops Lose Ca;
Thiazides cause rebsorption of Ca

3)
a) Dec Heart Rate;
Dec Heart Contractility;
Modulate Symp outflow from central and peripheral NS;
Dec release renin from juxtaglomerular apparatus
b) Elderly and African Americans;
BC beta-blockers dec BP by decreasing release of Renin from JG Apparatus
c) BC it will block the epinephrine from binding beta-receptors in the event of an asthma attack

4)
a) CHF;
Diabetes bc they are renal-protective
b) They cause more vasoconstriction of the Eff than the Aff arteriole -->
Inc GFR
c) Cough

5)
a) ARBs do not cause cough;
ARBs are NOT as effective for pts w/ CHF and diabetic nephropathy

6)
a) Dilitiazem,
Verapamil,
Dihydropyridines
b) Cause peripheral vasodilation
c) Depress the AV node and myocardial contractility