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196 Cards in this Set
- Front
- Back
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HPV Vaccination
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Age 9-26 (Gardasil 11-26, Gardasil 9 9-26, Cervarix 10-25).Series of 3 over 6 months on 0,1,6 month schedule
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Adolescent syphilis screening
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when sexually active. PRN or with pap smear, etc.
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self breast/testicular exams
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monthly starting in adolescence
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HIV screening
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start depending on sexual activity and/or IV drug use and assess knowledge of prevention
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Td or Tdap
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start as early as age 7, repeat every 10 yearscan substitute 1 dose of Tdap for Td
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meningococcal vaccine
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start age 11-18re vaccinate only high risk living situation (dorm room) after 5 years from last
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influenza vaccine
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annual vaccination
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pneumococcal vaccine
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age 65age 19-64 in smokers or those with asthmaPPSV23: age 19-64 who is smoker, asthma, COPD, DM, alcoholismat risk drugs or NH resident
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PPD screening
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start in adolescencerepeat every 2 years for those at risk for TB
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Pap smears
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include GC and chlamydia screen if < 25cytology, repeat every 3 yearsHPV co-test > 30 years, repeat every 5 yearsd/c age > 65 with 3 consecutive abnormal cytology tests and no abnormal tests in the past 10 years
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Clinician breast exam
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start adolescence, repeat q3 yearsrepeat q1 year at age 40
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BP screening
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with every healthcare visit or every 2 years
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Fasting lipid panel
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start age 20repeat q5 years unless chol > 200
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dental cleaning & checkups
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start young adultrepeat q6-12 months
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complete physical exam
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ages 11-14, 15-17, 18-21every 5-6 years from age 20-59every 2 years from age 60 (+routine labs)
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mammography
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various recommendationsannually age 45-54, q2 years after 55annually or q2 years age 50-74Continue as long as in good health and expected to live 10+ yearsno specific recommendation at 75
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prostate screening
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annual DRE and PSA starting age 50start age 40 if family hx of prostate CA or black
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ECG
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age 40 and PRNevery 2 years starting age 60
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Colorectal cancer screening
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start age 50annual fecal occult bloodflexible sigmoidoscopy q5 yearscolonoscopy q10 years OR double contrast barium enema q5-10 years
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tonometry
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glaucoma screeningannually starting age 40
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Herpes zoster vaccine (zostavax)
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once at age 60
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incidence
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frequency/rate of new cases
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prevalence
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proportion of population affected
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adolescent (12-19) major CoD
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MVCsuicideaccidentshomicidemalignancycardiovascular or congenital disease
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young adult (20-39) major CoD
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MVChomicidesuicideinjuriesheart diseaseAIDS
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Middle aged (40-59) major CoD
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heart diseaseaccidentslung cancerstrokebreast and colorectal cancerCOPD
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Elderly (> 60) major CoD
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heart diseasestrokeCOPDpneumonia and/or influenzalung and colorectal cancer
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top 4 US CoD
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heart diseasecolorectal cancerlower respiratory diseasestroke
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highest cancer mortality in women
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lung
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leading GYN cancer mortality
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ovarian
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highest cancer incidence in women excluding skin
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breast
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highest cancer mortality in men
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lung
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highest cancer incidence in men excluding skin and 2nd highest cancer mortality
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prostate
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top 2 cancer mortalities in both sexes
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lungcolorectal
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myplate
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1/2 fruits and vegetablesskim or 1% milk1/2 grain = whole grainvary protein choices
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Dietary intake guidelines
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carbs 55-60%fats < 30% (<10% saturated)protein = 0.8-1 g/kg/day (increase during illness)
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exercise
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30 min/day on most days of weeksustain target HR for 30 minover age 35: h&p and exercise stress test prior to initiation of exercise program
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ginger
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increased risk of bleeding
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ginseng
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increased risk of bleedingBP changesmania in depressed patients on MAOIsinhibitive effect on opioids
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st. john's wart
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increases risk of blood clottingmany drug-drug RXNsmay lead to cataract formation
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echinacea
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anaphylaxishepatotoxicnephrotoxicpotentiation of anesthesia
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gingko biloba
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increased risk of bleedinghypertension
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black cohosh
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seizures, visual disturbances, bradycardiaincrease risk of vaginal bleedingmimics effects of estrogen
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evening primrose
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hyperglycemiaincreased risk of epilepsy if taking antipsychoticsincreased incidence of seizures in patients with seizure disorder requiring anesthesia
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kava kava
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hypotension, liver damage, visual impairment, dry skinalcohol increases toxic effectsworsening of parkinson's symptomsimpaired reaction time
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garlic
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increases risk of bleeding
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HIPAA Title 1
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Comprehensive Omnibus Reconciliation Act
(COBRA) |
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HIPAA Title 2
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Administrative Simplification provisions provide national standards for EHR
Office of Civil Rights Enforces |
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HIPAA Covered Entities
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Health plans
Most health care providers Healthcare clearing houses |
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Healthy People 2020
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Increase quality and years of life
Eliminate health disparities |
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Mandatory Reporting
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Department of Health:
Gonorrhea Chlamydia Syphilis HIV TB Animal Bites (DHHS) Suspected child/elder abuse |
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Medicare Parts
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Part A: Everyone > 65; inpatient, SNF services, home healthcare
Part B: Outpatient services Part C: A + B; Allows HMO/PPO Part D: Prescription drug coverage |
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Credentials
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Minimum level of acceptable performance
Includes licensure and certification |
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Licensure
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Establishes qualification to perform role
Granted by State Board of Nursing |
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Certification
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Indicates mastery of specific content
Granted by nongovernmental organizations (ANCC, AANP, AACN) |
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nonmaleficence
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do no harm
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utilitarianism
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produce the greatest good for the greatest number of people
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beneficene
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prevent harm and promote good
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justice
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duty to be fair
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veracity
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duty to be faithful
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autonomy
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duty to respect an individual's thoughts and
actions |
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Types of Pain
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Acute < 6 months
Chronic > 6 months cutaneous visceral somatic neuropathic |
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Fever vs. hyperthermia
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Hyperthermia >37
Fever >38.3 |
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Causes of noninfectious post–op fever
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#1 atelectasis
increased BMR dehydration drug RXN's (amphotericin B, bactrim, beta–lactams, procainamide, INH) |
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Headaches
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tension: vise–like, generalized, neck or back of head; analgesics, relaxation
migraine: classic (with aura), common (without aura); 2–72 hours in duration, typically follow trigeminal pathway; F > M, triggers; unilateral throbbing, build gradually; avoid triggers, prophylaxis if >2–3 times/month (amitryptyline), sumatriptan for acute attack cluster: < 2 hours, perioribital pain, nasal congestion/eye redness; 100% oxygen, sumatriptan |
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albumin
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< 3.5 g/dL = malnutrition
< 2.7 g/dL = edema |
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normal urine sodium
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10–20 mEq/L
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normal serum osmolality
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280–290 (2 x normal sodium 140)
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isotonic hyponatremia
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etiology: pseudohyponatremia, hyperlipidemia, hyperproteinemia
treatment: decrease dietary fat |
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hypotonic hyponatremia
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etiology: free water excess
check urine sodium: < 10 = dehydration, diarrhea, vomiting >20 = diuretics, ACEi, mineralcort. deficiency hypervolemic = edema, CHF, liver Dz, advanced renal failure (restrict fluids) |
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hypertonic hyponatremia
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etiology: hyperglycemia (HHNK)
hypovolemic = give NS urine sodium > 20, treat cause can give NS + loop diuretic |
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hypokalemia
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etiology: chronic diuretic use, GI loss, excess
renal loss, alkalosis, elevated serum epinephrine (trauma) s/sx: weakness, fatigue, muscle cramps, ileus, broad T wave. < 2.5 paralysis, tetany, hyporeflexia, rhabdo treatment: > 2.5 = PO replacement |
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hyperkalemia
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etiology: dietary intake, renal failure, NSAIDS,
hypoaldosertoneism, cell death, acidosis K+ increase 0.7 mEq/L per 0.1 decrease in pH s/sx: weakness, paralysis, abdominal distention, diarrhea, tall peaked T treatment: insulin 10 units + 1 amp D50, exchange resin (kayexalate) |
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normal calcium
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normal ranges:
total calcium 8.5–10.5 mg/dL (2.2–2.6 mmol/L) ionized calcium 4.5–5.5 mg/dL (1.1–1.4 mmol/L) corrected calcium (mg/dL) = total calcium (mg/dL) + 4.0 – serum albumin (g/dL) |
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hypocalcemia
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etiology: hypoparathyroidism, hypomagnesemia, pancreatitis, renal failure, trauma, multi–blood transfusions
s/sx: increased DTR, carpopedal spasms (trousseau's), chvostek's sign, prolonged QT treatment: acute = calcium gluconate chronic = supplements, aluminum hydroxide |
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hypercalcemia
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etiology: hyperparathydroidism,
hyperthyroidism, vitamin D intoxication, prolonged immobilization, thiazide diuretics s/sx: muscle weakness, fatigue, nausea/vomiting, constipation, coma Serum Ca > 12 = medical emergency treatment: calcitonin, dialysis If < 12, NS + loop diuretic |
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anion gap equation
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gap = Na + K – HCO3 – Cl
normal gap = 8–16 (variable, 14 +/– 5) |
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TBSA + Parkland Formula
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Rule of Nines:
Head 9% Arms 9% Chest/Abdomen 18% Back 18% Legs 18% Genitals 1% 4 mL/kg x TBSA = 24 hour requirement 1/2 given in first 8 hours 1/2 given in remaining 16 hours |
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Indications for prophylactic intubation in burn victims
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burns to face
singed nares/eyebrows dark soot/mucous from nares or mouth |
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common cause and treatment of cellulitis
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outpatient:
1) strep pyogenes (group A) 2) staph aureus 3) other strep (group B,C,G) – rare inpatient: 1) gram negatives (E.coli, klebsiella, pseudomonas, enterobacter) 2) staph aureus (MRSA) 3) strep MRSA: bactrim doxycycline/minocycline clindamycin Group A strep: bactim/doxycycline + PCN/keflex OR clindamycin |
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organophosphate poisoning
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s/sx: GI upset, blurred vision, miosis (constricted pupils), bradycardia, AMS, slurred speech
treatment: atropine (drug of choice) charcoal for ingestion |
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antidepressant toxicity
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s/sx: AMS, hallucinations, blurred vision, urinary retention, hypotension, tachycardia, dysrhythmias, hypothermia, seizures
treatment: gastric lavage/charcoal, IV NaHCO3 for dysrhythmias, benzodiazepines for seizures serotonin syndrome: dantolene sodium, clonazepam for rigors |
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transplant rejection
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presentation:
flu–like symptoms immediate failure of organ immediate biopsy warranted |
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transplant prophylactic drug therapy
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calcineurin inhibitor (prograft, cyclosporine)
antimetabolite (imuran, cellcept) steroid (prednisone) |
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herpes zoster
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if suspected ocular involvement, refer to
opthalmologist post–herpetic neuralgia: gabapentin, pregabalin |
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skin cancers
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squamous cell carcinoma (develop over months, firm, irregular papule, sun exposed areas, 3–7% metastasis)
Basal cell carcinoma (most common, develop over years, waxy, volcano–like appearance, telangiectatic vessels) Malignant Melanoma (highest mortality rate, median age 40) Asymmetry Border irregularity Color variation Diameter > 6 mm Elevation Enlargement |
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keratoses
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actinic (pre–squamous cell, small patches, may be tender, rough, flesh–colored, pink or hyperpigmented; liquid nitrogen)
seborrheic (benign, nonpainful, beige/brown/black plaques, stuck–on appearance, 3–20 mm diameter; no treatment or liquid nitrogen) |
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Metabolic Syndrome
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At least 3:
Waist circumference >35 (F), >45 (M), inches BP >130/85 Triglycerides > 150 Blood Glucose > 100 HDL < 50 (F), < 40 (M) |
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Diagnostics DM Type I/Type II
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polyuria, polydipsia, and weight loss
Random plasma glucose > 200 mg/dL Fasting blood sugar > 126 (2 separate days) ketonemia, ketonuria (Type I) Hgb A1c > 7% |
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DM Type I initial management
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If presenting with ketones:
Insulin 0.5 units/kg/day, give 2/3 in AM |
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Conventional split dose mixtures insulin
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AM dose: 2/3 NPH + 1/3 Regular
PM dose: 1/2 NPH + 1/2 Regular |
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Oral Antidiabetics
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Biguanides: Metformin (lactic acidosis)
Sulfonylureas: Glipizide, glyburide, glimepiride (stimulate pancreas to release insulin) Alpha–glucosidase inhibitors: acarbose, miglitol (bind disaccharides to decrease absorption in gut) Thiazolidinediones: avandia, actos (heart failure) non–sulfonylureas insulin release stimulators: repaglinide (prandin), nateglinide (starlix) (mimic rapid acting insulin) |
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Somogyi Effect
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nocturnal hypoglycemia causes rebound AM
hyperglycemia; reduce HS insulin |
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Dawn Phenomenon
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"the dawn is rising"
insulin desensitization at night (progressive increase in blood glucose); add HS insulin |
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Treatment DKA
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NS x1L in 1st hour, then 500 mL/hr
If glucose > 500; use 1/2 NS after 1st hour when glucose < 250, change to D5 1/2 NS 0.1 unit/kg regular insulin, then 0.1 unit/kg/hour If glucose decrease < 10% after 1 hour, repeat bolus dose Severe acidosis (pH < 7.1), HCO3 drip |
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Treatment HHNK
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Massive NS replacement (may be 6–10L deficit), then 1/2 NS followed by D5 1/2 NS
15 units regular insulin IV + 10–15 units SC |
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Treatment Hyperthyroidism
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Propanolol for symptomatic relief 10–80 mg QID
methimazole 30–60 mg q3 days in 3 doses OR propylthiouracil 300–600 mg daily in 4 doses If surgical, must be euthyroid prior; Lugol's solution 2–3 drops daily x10 days (reduce vascularity of thyroid) |
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Treatment Thyroid Storm
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Propylthiouracil (PTU) 150–250 mg q6h
OR Methimazole 15–25 mg q6h + (lugol's solution OR sodium iodide + propanolol + hydrocortisone) avoid ASA |
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Treatment hypothyroidism
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levothyroxine 50–100 mcg daily, increase by 25 mcg q1–2 weeks until stable
decrease dose > 60 years old |
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Treatment Myxedema Coma
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Levothyroxine 400 mcg IV x1, then 100 mcg daily
slow rewarming with blankets |
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Cushing's Syndrome
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s/sx: central obesity, moon face, hisuitism, hypertension, weakness, headache
dx: hyperglycemia, hypernatremia, hypokalemia, dexamethasone suppression test, serum ACTH tx: transphenoidal resection pituitary, stop inciting drugs, manage electrolyte imbalance |
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Addison's Disease
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s/sx: hypotension, scant hair, fever, AMS
dx: hypoglycemia, hyponatremia, hyperkalemia, elevated ESR, cortisol < 5 mcg/dL @ 0800 tx: glucocorticoids +/– mineralcorticoid (hydrocortisone, fludrocortisone acetate) hydrocortisone 100–300 mg IV with NS, then D5NS 500 mL/hr x4 hours, then taper |
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SIADH
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s/sx: AMS, decreased DTR, hypothermia, edema, nausea/vomiting, cold intolerance
dx: euvolemic hyponatremia, serum osmolality <280, urine osmolality > 100, Urine Na > 20 tx: restrict fluids 1L/day, IVF + lasix, tolvaptan |
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Diabetes Insipidus
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s/sx: thirst, polyuria 2–20L/day, AMS, tachycardia, hypotension, hyperthermia
dx: hypernatremia, elevated BUN/creat, serum osmolality >290, urine osm < 100, urine spec grav < 1.005 tx: Na > 150 = D5W IV to replace 1/2 volume deficit in 12–24 hours, when Na < 150 substitute NS, DDAVP 1–4 mcg IV/SC q12–24 hours |
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Pheochromocytoma
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s/sx: labile hypertension/tachycardia/diaphoresis/hyperglucemia, headaches, weight loss
dx: normal TSH, plasma–free metanephrines: plasma normetanephrine >2.5pmol/mL OR metanephrine >1.4 pmol/mL 24 hour urine > 2.2 ug metanephrine per mg creatinine AND > 5.5 ug vanillylmandelic acid per mg creatintine CT adrenals to confirm tumor tx: tumor removal, alpha adrenergics pre–op (phentolamine), then convert to phenoxybenzamine post–op: watch for hypotension, adrenal insufficiency, hemorrhage |
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Etiology of S3
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increased fluid states (CHF, pregnancy, etc.)
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Etiology of S4
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stiff ventricular wall (MI, LVH, HTN)
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NYHA Heart Failure Classification
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I– no limitation of physical activity
II– slight limitation of physical activity but comfortable at rest III– marked limitation of physical activity but comfortable at rest IV– severe limitation, uncomfortable at rest |
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Heart Failure Management
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sodium restriction, increase physical activity, weight reduction
ACEi/ARB + diuretics |
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JNC–7 & JNC–8 definition of hypertension
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JNC–7:
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HTN drugs of choice
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Non–african: thiazide, CCB, ACEi
African: thiazide, CCB Adults with CKD: ACEi (regardless of race) |
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Peripheral Vascular Disease
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Incidence: 40–70 years of age
Etiology: atherosclerosis S/Sx: claudication, cold/numb extremities, progresses to pain at rest, shiny/hairless, dependent rubor, pallor/cyanosis, diminished pulses, ulcerations Dx: doppler u/s, ankle–brachial index, arteriography Tx: smoking cessation, daily exercise, pentoxifylline (trental), cilostazol (pletal), weight reduction, smoking cessation, angioplasty, amputation |
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Chronic Venous Insufficiency
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Incidence: Women > Men
Etiology: leg trauma, genetic? S/Sx: aching relieved by elevation, dependent edema, night cramps, trophic changes, stasis leg ulcers, edema, dermatitis, cool extremities Dx: clinical Tx: elevation, TEDs, weight reduction, treat ulcers (wet compress, local corticosteroids, systemic abx if evidence of bacterial infection) |
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Pericarditis
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Etiology: viral (most common), MI, renal failure, neoplastic, endocarditis, collagen d/o, drug induced, trauma
S/Sx: localized pleuritic retrosternal/precordial chest pain, pain relieved by sitting forward, pericardial friction rub, +/– fever Dx: ST elevation all leads x days (followed by transient T wave inversion), PR segment depression, ESR elevation, ECHO Tx: NSAIDS are DoC, corticosteroids only if failure of NSAID therapy for weeks with relapse of pericarditis, Codeine for pain |
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Endocarditis
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Pathology: infection of endothelial surfaces of heart (usually affects valves)
Etiology/Incidence: bacterial (most common), IVDA, IV therapy/TPN, valvular heart disease, GU surgery or instrumentation, dental sx, burns, HD S/Sx: fever, malaise, night sweats, weight loss new murmur (30%), Osler's nodes (painful red nodules in phalanges), splinter hemorrhages, splenomegaly (50%), Janeaway lesions (rare, nonpainful macules on palms and soles), Roth spots (white retinal infarcts w/surrounding hemorrhage), leukocytosis w/left shift, ECHO, BCUL x3, ESR elevated (near 100%) Tx: treat underlying cause (empiric abx if acutely ill); penicillin G + Gentamicin OR Nafcillin OR vancomycin |
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Normal Range CVP
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0–6
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Normal Range PAP
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15–25 / 5–15
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Normal Range PCWP
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6–12
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Normal Range Cardiac Output
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HR x SV
4–8 L/min |
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Normal Range Cardiac Index
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More accurate measure than CO (uses body surface area)
2.5–4 L/min |
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Normal Range SVR
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(MAP – mean CVP x 80) / CO
800–1200 dynes/sec/cm^5 |
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Normal Range SvO2
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60–80%
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Hypovolemic Shock
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CO/CI: low
CVP: low PCWP: low SVR: HIGH SvO2: low tx: restore volume |
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Cardiogenic Shock
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CO/CI: low
CVP: HIGH PCWP: HIGH SVR: HIGH SvO2: low tx: careful IVF, vasopressor, nitro IV if needed (MI) |
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Distributive Shock
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septic, anaphylactic, neurogenic
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Septic Shock
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CO/CI: HIGH then low
CVP: low then HIGH PCWP: low then HIGH SVR: low SvO2: low then HIGH tx: antibiotics, IVF, vasopressor |
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Anaphylactic Shock
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CO/CI: low
CVP: low PCWP: low SVR: low SvO2: low tx: diphenhydramine 25–75 mg IV/IM, epinephrine 0.3–0.5 mg SQ/IM if resp distress, IVF, IV steroid?, H2 antagonist?, inhaled b–agonist |
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Neurogenic Shock
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CO/CI: low
CVP: low PCWP: low SVR: low SvO2: low tx: IVF, vasopressor |
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Obstructive Shock
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CO/CI: low
CVP: High PCWP: low SVR: normal/low SvO2: HIGH tx: IVF, vasopressor, treat cause (tPA?) |
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Hospitalization in Asthma
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FEV1 < 30% predicted or does not improve to > 40% predicted after 1 hour therapy
peak flow < 60 L/min or does not improve to > 50% predicted after 1 hour therapy |
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Outpatient Management Asthma
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1) SABA
2) inhaled corticosteroid 3) increase dose of steroid or SABA 4) inhaled anticholinergic (ipratropium) 5) antileukotrienes (singulair) |
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Inpatient Management Asthma
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oxygen, IVF
inhaled SABA methylprednisone 60–125 x1, then 20 mg q4–6 SQ epinephrine anticholinergic (atrovent) |
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Outpatient Management COPD
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ipratropium or SABA
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Inpatient Management COPD
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oxygen, IVF, antibiotics x7–10 days if purulent sputum
ampicillin, amoxicillin, doxycycline, bactrim |
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Tuberculosis
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Organism: M. tuberculosis
s/sx: asymptomatic, fatigue, anorexia, night sweats, weight loss, cough dx: culture of M. tuberculosis x3, AFB smear (presumptive), CXR with small homogenous infiltrate in upper lobes, PPD (exposure, not active) PPD + 5mm (HIV), 10 mm (at risk), 15 mm (low risk) Tx: report to health department INH, rifampin, pyazinamide, ethambutol or streptomycin if susceptible to INH and RIF, drop 4th drug 1st 3 drugs x2 months, then 4 more months of INH and rifampin If concurrent HIV, treat 9 months monitoring: weekly sputum smear and culture for 6 weeks, then monthly until negative; LFT, CBC, creatinine at baseline; if ethambutol, then visual acuity and red–green color perception test |
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Outpatient Community Acquired Pneumonia
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organism: strep pneumoniae
tx: < 60 years old + no comorbidities macrolide = azithromycin >60 years old OR comorbidities fluroquinolone = levaquin, moxifloxacin, gemfloxacin |
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ICU Management Com Acquired Pneumonia
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organisms: strep pneumoniae, pseudomonas
beta lactam + azithro OR fluoroquinolone if psuedomonas: zosyn/cefepime/imipenem + cipro/levaquin OR aminoglycoside + azithromycin/antipneumococcal fluoroquinolone if beta lactamase +, use vanc or linezolid instead of beta–lactam |
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HAP vs. VAP vs. HCAP
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HAP: onset > 48 hours after admission; staph aureus, strep pneumoniae, H. influenzae
VAP: onset >48 hours after intubation; pseudomonas HCAP: onset < 90 days after 2 day admission, residing in nursing home, or < 30 days after receiving chemotherapy, IV antibiotics, or wound care; staph aureus, psuedomonas >> strep pneumoniae, h.flu, MRSA |
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Pleural Effusion: transudate vs. exudate
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exudate:
fluid protein:serum protein > 0.5 fluid LDH:serum LDH > 0.6 fluid LDH > 2/3 upper limit of serum LDH |
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Cranial Nerves
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1–opthalmic–S
2–optic–S 3–oculomotor–M 4–trochlear–M 5–trigeminal–B 6–abducens–M 7–facial–B 8–vestibulocochlear–S 9–glossopharyngeal–B 10–vagus–B 11–spinal accessory–M 12–hypoglossal–M |
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TIA
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cerebral insufficiency lasting < 24 hours without any residual deficit
1/3 have CVA within 5 years tx: aspirin, plavix, endarterectomy (>70% stenosis AND symptomatic) manage hypertension |
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Partial Seizures types
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simple partial– no LOC, single muscle group spreading to entire side of body
complex partial– simple partial followed by LOC |
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Generalized Seizures types
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Absence– blank stare, common in children
tonic–clonic– usually last 2–5 minutes followed by postictal period status epilepticus– series of tonic–clonic seizures lasting > 10 minutes |
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Seizure Treatment
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dx: EEG (determine type), CT head
tx: valium 5–10 mg IV (status epilepticus), ativan 2–4 mg IV, long term management |
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Myasthenia Gravis
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autoimmune reduction of acetylcholine receptors at neuromuscular junction
incidence: age 20–40, more common in women s/sx: ptosis, diplopia, weakness, fatigue, normal DTR dx: Anti–aceylcholine receptor Ab (85%), edrophonium test (r/o cholinergic crisis) tx: pyridostigmine bromide, immunosuppression, PLEX, plasmapheresis |
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Guillian–Barre Syndrome
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etiology: unknown, viral? (1–3 weeks after infection)
s/sx: decreased DTR, progressive symmetrical ascending paralysis dx: leukocytosis with left shift, LP/MRI/CT tx: supportive care |
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Bacterial Meningitis
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80–90% caused by S.pneumoniae, H.flu, Neisseria meningitidus
fever, nuchal rigidity, headache; kernig sign (pain in hamstrings), brudzinski's sign (flexion of legs with flexion of head), photophobia, seizures dx: CT then LP (elevated protein, low glucose) tx: baord spectrum abx (vanc, rocephin) |
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Autonomic Dysreflexia
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Associated with injury at/above t4–t6, autonomic response to noxious stimuli
s/sx: diaphoresis/flushing above level of injury, chills/vasoconstriction below level of injury, hypertension, bradycardia, headache, nausea tx: antihypertensives and remove stimulus |
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Parkinson's Disease
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Insufficient dopamine availability
s/sx: tremor, rigidity, bradykinesia dx: none tx: increase dopamine availability (carbidopa–levodopa), anticholinergics for rigidity (benztropine Cogentin) |
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Peptic Ulcer Disease
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Cause/Incidence: duodenal ulcers age 30–55, gastric ulcers age 55–65, more common in smokers (>1/2 ppd)
s/sx: eating relieves pain (duodenal) or worsens (gastric), GI bleed (20%), perforation (5–10%) dx: endoscopy after 8–12 weeks treatment, h.pylori testing tx: triple therapy = 2 abx + ppi or bismuth MOC= metronidazole, omeprazole, clarithromycin AOC= amoxicillin, omeprazole, clarithromycin MOA= metronidazole, omeprazole, amoxicillin antiulcer therapy continues for 3–7 weeks |
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Hepatitis A
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etiology: fecal–oral, parenteral
2–6 week incubation period dx: anti–HAV + in acute/recovered, IgM = acute, IgG = recovered |
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Hepatitis B
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Active= HBsAg, HBeAg, Anti–HBc, IgM
Chronic= HBsAg, Anti–HBc, Anti–HBe, IgM, IgG Recovered= Anti–HBc, Anti–HBsAg |
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Hepatitis C
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PCR required to differentiate acute/chronic
Anti–HCV, HCV RNA tx: increase fluids 3–4 L/day, limit protein intake, no hepatotoxins, oxazepam for sedation if needed |
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Grey–turners sign
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flank discoloration suggests hemorrhage
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cullen's sign
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umbilical discoloration suggests hemorrhage
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Ranson's criteria
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prognosticative tool for pancreatitis mortality
On Presentation Age > 55 WBC > 16,000 Glucose > 200 LDH > 350 AST > 250 Within 48 hours Hct drop > 10 BUN increase > 5 Calcium < 8 SaO2 < 60 Base Deficit > 4 Fluid sequestration > 6L |
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Psoas sign
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pain right right thigh extension
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obturator sign
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pain with internal rotation of flexed right thigh
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rovsing's sign
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RLQ pain with palpation of LLQ
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UTI– Most common organisms by gender
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Female– E. coli
Male– Proteus species |
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Lower UTI
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S/Sx: dysuria, hematuria
Dx: UA > 10 WBC, +/– nitrate, +Esterase Tx: Lower UTI– 3 day (preferred) vs. 7 day course Bactrim, Cipro, Augmentin Amoxil, levaquin, macrobid, trimethoprim, fosfomycin If pregnant, amoxil, macrobid, keflex for FULL COURSE (7–10 days) |
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Upper UTI
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14 day vs. 6 week course
Bactrim, quinolone, augmentin, aminoglycoside Hospitalize if nausea/vomiting, severe illness |
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Criteria for dialysis
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Acidoses/Azotemia
Electrolyte Disturbances Intoxication Oliguria Uremia |
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Prerenal vs. Intrarenal AKI
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Prerenal:
BUN:Creat Ratio > 10/1 Urine Na < 20 Urine Spec Grav. > 1.015 Urine FeNa < 1 Intrarenal: Urine granular/white casts |
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Gonorrhea
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Causative organism: Neisseria gonorrhoeae (gram neg diplococci)
incidence: 1–2% population, 80–90% male to female transmission, leading cause infertility s/sx: often asymptomatic, dysuria, green discharge dx: gram stain and culture tx: rocephin IM x1 (gon.)+ zithromax (chlamy) |
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Syphillis
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Organism: treponema pallidum (spirochete)
incidence: 3rd most common reported s/sx: primary– painless chancre secondary– flu–like symptoms, skin rash (palmar/plantar) latent tertiary–neuro/CV, leukoplakia Dx: VDRL/RPR, if positive– FTA–ABS, MHA–TP Tx: Penicillin G (x1 if < 1 year, < latent, otherwise weekly x3 weeks) |
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Chlamydia
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organism: chlamydia trachomatis
incidence: most common STI s/sx: asymptomatic, dysuria, painful intercourse dx: chlamydia culture, Enzyme immunoassay (preferred) tx: azithromycin + rocephin IM (gonor.) |
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vulvovaginitis
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inflammation of vulva/vagina
dx: wet prep 1) trichomonas– strawberry patches cervix, painful intercourse, dysuria; flagyl 2) bacterial vaginosis– watery/gray d/c; flagyl, clindamycin 3) candidiasis– white d/c; miconazole |
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herpes
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organism: HSV1, HSV2
s/sx: fever, malaise, dysuria intial– painful ulcers (~12 days) recurrent– less painful ulcers ~5 days dx: papanicolaous or tzanck stain, viral culture tx: symptomatic, acyclovir, valacyclovir for asymptomatic viral shedding of HSV2 |
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Common Causes of Anemia by MCV
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Microcytic– Iron Deficiency, thalassemia
Macrocytic–B12, Folate, alcoholism, liver failure, drugs Normocytic– Chronic disease, sickle cell, renal failure, blood loss, hemolysis |
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Iron Deficiency Anemia
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Type: microcytic, hypochromic
etiology/incidence: most common type of anemia; blood loss, inadequate iron intake, impaired absorption s/sx: Pica dx: low serum iron, low ferritin, high TIBC tx: ferrous sulfate, increase intake (raisins, red meat, spinach, kale, etc.) |
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Thalassemia
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Type: microcytic, hypochromic
etiology/incidence: genetic inheritance (Mediterranean, African, middle eastern, indian, asian) s/sx: none unless severe dx: normal TIBC, normal Ferritin. decreased alpha or beta Hgb tx: none unless severe, NO IRON |
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Folic Acid Deficiency
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Type: macrocytic, normochromic
etiology/incidence: inadequate folate intake, decreased folate absorprtion s/sx: glossitis (big red tongue), anorexia dx: decreased serum folate, RBC folate < 100 ng/mL tx: folate 1 mg daily, increase intake (bananas, peanut butter, fish, green–leafy vegetables) |
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Pernicious Anemia
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Type: macrocytic, normochromic
etiology/incidence: intrinsic factor deficiency results in decreased absorption of B12 s/sx: glossitis, paresthesias, loss of vibratory sense, loss of fine motor control; Romberg sign, Babinski sign dx: Serum B12 < 0.1 mcg/mL, Anti–IF and antiparietal cell Ab test, schilling test (determine cause) tx: Cyanocobalamin 100 mcg IM daily |
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Anemia of Chronic Disease
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Type: normocytic, normochromic
etiology/incidence: 2nd most common cause, chronic inflammation, infection, renal failure, malignancy; decreased RBC lifespan? dx: serum iron and TIBC low, serum ferritin > 100 ng/mL tx: Treat underlying cause, nutritional support, E–poetin? |
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Sickle Cell Anemia
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etiology/incidence: genetic inheritance
s/sx: sudden onset severe pain, aching joint pain dx: peripheral smear, gel electrophoresis (confirm Hgb genotype) tx: IVF, pain control, oxygen to treat hypoxemia |
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Leukemias
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Neoplasms arising from hematopoietic cells in bone marrow
More frequent in males Acute Myelogenous Leukemia (AML) Chronic Myelogenous Leukemia (CML) Acute Lymphocytic Leukemia (ALL) Chronic Lymphocytic Leukemia (CLL) s/sx: generalized lymphadenopathy, weight loss, anorexia, fatigue, weakness dx: abnormal RBCs/neutrophils, elevated ESR, peripheral blood smear, bone marrow biopsy to confirm tx: chemotherapy, bone marrow transplant |
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Acute Myelogenous Leukemia (AML)
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most common acute leukemia in adults
50–85% remission survival 40% |
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Chronic Myelogenous Leukemia (CML)
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age >40
median survival 3–4 years Philadelphia Chromosome(hallmark) |
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Acute Lymphocytic Leukemia (ALL)
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90% remission in children (much less in adult) pancytopenia with circulating blasts(hallmark)
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Chronic Lymphocytic Leukemia (CLL)
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most common leukemia in adults
middle–old age median survival 10 years lymphocytosis (hallmark) |
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Lymphoma
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lymphocytic malignancy
diagnosed by lymph node biopsy (> 1 cm x4–6 weeks and not associated with infection) staging: 1– single node or group 2– >1 node group on same side of diaphragm 3– lymph nodes or spleen on both sides of diaphragm 4– liver or bone marrow involvement Hodgkin's Non–Hodgkin's dx: MRI to locate and stage, biopsy and histopathologic exam to confirm tx: radiation, chemo, bone marrow transplant |
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Hodgkin's Disease
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etiology unknown
most common males aged > 32 years cervical adenopathy spreading in predictable pattern Reed–Sternberg cells (hallmark) |
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Non–Hodgkin's Lymphoma
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viral etiology?
most common neoplasm age 20–40 less predictable spread than Hodgkin's |
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Idiopathic Thrombocytopenic Purpura
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etiology/incidence: autoimmune destruction of platelets w or w/o suppression of thrombopoiesis, women:men = 3:1
s/sx: rarely bleeding causing need for hospitalization, bleeding gums, hematuria dx: bone marrow aspiration (r/o SLE), diagnosis of exclusion for thrombocytopenia tx: may not be necessary if plt > 20,000, steroids/IgG may elevate platelet count within 2–3 days, IgG preferred in HIV, plt transfusion if necessary HIT tx= argatroban or lepirudin (and d/c heparin) |
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Disseminated Intravascular Coagulation
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Pathophysiology: activation of coagulation cascade and fibrinolytic system. thrombin converts fibrongen to fibrin, producing microclots. Coagulation factors are reduced. Circulating plasmin activates fibrinolytic system, lysing fibrin clots into fibrin degradation products (FDPs). Hemorrhage 2/2 anticoagulant activity of FDP and depletion of coagulation factors
etiology/incidence: Mortality rate 50–85%; neoplasm, sepsis, liver disease, trauma, burns, shock, OB complications, acute leukemia s/sx: varies greatly in severity dx: platelets < 150,000, fibrinogen < 170, decreased RBC, FDP > 45, PT > 19, PTT > 42, D–Dimer + tx: treat underlying cause, platelets, FFP (clotting factors), cryoprecipitate (fibrinogen), heparin? |
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HIV/AIDS
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s/sx: flu–like symptoms during seroconversion (3 weeks – 6 months), fever, night sweats, weight loss
AIDS = CD4 < 200 and/or presence of opportunistic infection dx: ELISA (initial screening), western blot test (confirmation) tx: AART (active antiretroviral therapy), when to start controversial, treat CD4 < 350; Bactrim DoC for PCP |
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Osteoarthritis
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etiology: degenerative joint disease, asymmetrical destruction of articular carilage. weight bearing joints + finger/hand/wrist
Incidence: 53–64 years, M = W, obesity, genetic predisposition s/sx: heberden's nodes (DIP), bouchard's nodes (PIP), pain worsens as day progresses, relieved by rest, crepitus dx: xray– narrowing of joint space, osteophytes, juxta–articularsclerosis, subchondral bone tx: ASA, NSAIDs, weight loss, cane, ice/heat, PT, replacement |
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Rheumatoid Arthritis
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etiology: autoimmune, symmetrical inflammation of connective tissue. PIP/MCP/wrist
Incidence: 35–50, W > M s/sx: inflammation to joints, worse in AM, improves throughout day, constitutional, weight loss dx: ESR elevated, ANA+ in 20%, synovial aspirate with inflammatory changes and WBCs, xray– joint swelling, progressive cortical thinning, osteopenia, joint space narrowing tx: high dose ASA, NSAIDs, DMARDs, corticosteroids, rest, PT, surgery rheumatology consult |
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subluxation
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incomplete dislocation
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compartment syndrome
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severe ischemic pain, skin perfusion and arterial pulses normal
tx: fasciotomy effective if performed within few hours |
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systemic lupus erythematosus
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etiology: autoimmune, can be drug–induced (lupus–like syndrome)– many drugs including: thorazine, hydralazine, methyldopa, procainamide, quinidine
incidence: women of childbearing age s/sx: constitutional, weight loss, butterfly rash (< 50%), raynaud's phenom. (20%), skin and joint manifestations, photosensitivity, vasculitis, organ system dysfunction, etc. etc. etc. dx: ANA + in 95%, antiphospholipid antibodies, anemia, leukopenia, thrombocytopenia tx: avoid fatigue, sun protection, topical glucocorticoids, NSAIDs, DMARDs |
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giant cell arteritis (temporal arteritis)
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vasculitis of temporal artery, can cause blindness
15% of all cases of fever of unknown origin in age > 65 incidence: age > 50 s/sx: headache, scalp tenderness, jawclaudication, visual changes, fever > 104F dx: very high ESR, normal WBC, temporal artery biopsy tx: prednisone, rheumatology consult |
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conjunctivitis vs corneal abrasion
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corneal abrasion = pain worsening with time, dx = sodium fluorescein stain, tx = abx eyedrop or sulfonamide drops, pressure patch x24 hours, NO steroids, NO anesthetic drops (after exam), refer if not healed in 24 hours
conjunctivitis = allergic (stringy), bacterial (purulent), viral (watery), STI (copious purulent) (ddx based on history and discharge). STI = rocephin + azithromycin (same doses) |
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glaucoma
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path: increased IOP (normal 10–20), open angle (chronic), closed angle (acute)
s/sx: cupping of disc (cup >50% disc diameter), constriction visual fields; closed–angle = extreme pain, blurry vision, halos, pupil dilated/fixed dx: tonometry tx: open–angle = a2 agonist, b antag, miotic closed–angle = diamox, mannitol, surgical |
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cataract
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path: opacification of lens
incidence: age >65 s/sx: painless, diplopia, halos tx: glasses, surgery |
