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340 Cards in this Set
- Front
- Back
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msk ankle
inversion sprain of ankle - tests - ligaments |
INVERSION
lateral ligaments Do anterior drawer Talar tilt #1 Ant talofibular lig #2 calcaneofibular lig |
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msk ankle
eversion sprain lots of swelling and pain after sig trauma - fell from big height |
medial lig sprain
needs lots of trauma deltoid lig assoc Potts fx medial malleolus (tibia) or fx both malleoli Medial muscle tendons T, D, Harry. Tibialis posterior flex dig longus flex hall longus post tibial art, vein, nerve |
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msk ankle
eversion of ankle and rotated while stumbled pain, wont bear weight, but not as much swelling as expect for pain/disability |
high ankle sprain
+squueze test point tender over ant post ankle spongy ankle separation of tibia from fibular at sydosmoses and interosseus mmb ant inf tibiofibular lig |
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msk ankle
ottowa ankle rules |
wont walk/limp 4 steps
point tender distal 6 cm malleous ant/post Do mid-foot also if: wont walk tender base 5th MTarsal or navicular (top of foot medial/middle) Ottowa not for kids so much Low specificity - false positives Under 15% ankle inj have fx |
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msk ankle
+skin lesion + h/o trauma, intermittent swelling and grinding, possible fragment talar dome |
skin ulcer -> osteomyselitits
Osetochondritis dessecans |
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msk arthritis
OA RA gout septic joint |
OA : pain with wt, better rest NSAIDS,
RA: multi joint, ulnar dev joints MCP gout : swelling, 1st toe MCP septic joint: RF IVDA/steroids |
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rot cuff muscles
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msk shoulder
Who: over 40, poor vasc ; lots overhead use Cause: fall onto shoulder/elbow Present: pain lateral on deltoid, pain worse at night. PE: + Neers and Hawkins |
Impingement
Usually supraspin, can be infra Rx: no xray, rest, ROM exercse |
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msk shoulder
Who: over 40, poor vasc ; lots overhead use Cause: fall onto shoulder/elbow Present: pain lateral on deltoid, pain worse at night. PE: + Neers and Hawkins Plus wasting infra and and supraspin muscles, weak ext rotation less pain passive vs active ROM |
complete rot cuff tear
If want sx do MRI rest. |
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msk shoulder
Pain ant, diffuse, worse after tennis/golf, baseball. PE: pain with supination forearm, flex albow. |
+ Speeds
biceps tendonitis. If tear, usually proximal. repair for comsmetic and for weak supination and flexion. |
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msk shoulder
Fell on point of shoudler/direct blow to post/lat shoulder. +crossover test |
Sprain/sep AC joint
Rx: ROM stength exercise |
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msk shoulder
M-aged pt with DM or thyroid dz Ltime shoudler pain pain over deltoid and resist ROM hurts when sleep on that side. poor passive and active ROM abduct, int and ext rotation/ |
adnesive capsultitis
PT steroids IF EARLY |
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msk shoulder
fall on lateral shoulder pain, swelling clavicle area |
clavicle fx
if post-inf dispalcement can PTX or plexus injury sling unless a kid |
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otc
oxymetazoline |
topical decongestant
also naphazoline 3 days max |
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otc
- age for cold meds - name antihist |
- 4 for cold meds
- name antihist: diphenhydramine, chlorphenerimine - expect: guarifensin |
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otc
spf meaning types |
SPF: 20 means stay 20x longer w/o burn.
SPF 15: 93% filtered. SPF 30: 96.7% dry shirt SPF 7 Water resist: 40' Waterproof: 80min Do 30 min before sun. Reapply 2 hrs. PHYSICAL barrier: zinc, titanium CHEMICAL: UVA: 320-340 longer wavelength, ages, skin changes, CANCER mexoryl/ecamsule UVB: 290-320, epidermis, burns PABA/aminobenzoic, salicylates, cinnamtes BOTH: avobenzone, benzopehenones, zinc Should be 6M old. |
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otc
analgesics max dose |
APAP:
adult 4 g / 4000 mg day children 10-15 mg/kg up to 5x day ASA: adult 4 g/ 4000 mg Ibu: adult 1200 mg, child 40 mg/kg SE: ulcer, renal hep failure, HTN, periph edema. keto: adult 75 mg naproxen: adult 600 mg |
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otc
-plan b is what - DEET |
levonorgetrol
a progesterone red chance preg 85-99% no CI except est preg --------------- DEET 10% last 2 hrs 23% lasts 5 hrs up to 50% safe KIDS: recc 10% (last 2 hrs) safe for over 2M to use 30% lemon euc or picarin ~ 10% DEET permetrin for clothes not people |
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msk knee
How: Injury when sudden decel when foot planted and twisted, pt then falls Pres: Immediate fast effusion +Lachman test: pt supine and knee at 15-30 degrees stablize femur and pull tibia forward |
ACL tear
Immed fast effusion as artery here. Pat often feels pop. |
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msk knee
How: car crash hit dashboard Pres: knee may be hyperflexed. |
PCL tear
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msk knee
How: injury in day, wake up next day and swollen. Pres: knee locks, also clicks of gives way in certain position. PE: + McMurray > joint line tenderness |
meniscus
pain mcmurray foot full int rotation: lat men foot full ext roto: med men mcmurray pain w/o clunk = DJD PE: also hemartrosis, dec ROM, quad wasting. |
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msk knee
valgus stress + |
MCL
valgus knock kneed bring foot lateral to knee |
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msk knee
varus stress |
LCL
varus bow legged bring foot in medial (knee sticks out) |
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msk knee
How: direct blow to lateral knee, PE: Joint effusion ABOVE patella, twisting injury where femur rotates medially with foot planted |
patellar dislocation
uncommon. usually lateral |
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msk knee
How: direct blow to anterior knee or avulsion to knee PE: acute fast swelling in joint |
patellar fracture
uncommon for all patellar pathology: INHIBITION TEST hold superior patella and have pt contract QUAD -> pain |
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msk knee
Overuse with jumping/kneeling. quad tendon pain STep stool test: one foot on floor, other on step of exam table. Lift foot off floor, place back down on heel, pain + |
patellar tendinitis
patellofemoral dysfx chondromalacia patella ant compartment pain w/ chondromalacia PE: + McMurray > joint line tenderness PLUS more pain with SQUAT |
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msk knee
joint effusion below patella |
prepatellar bursitits
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msk knee
wont bear weight or extend knee after a jump |
fx tibial tuberosity
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acne
whitehead vs black head |
comedone, OPEN, blackhead
open follicle with plug, and dark debris blackhead comedone, closed, papule with inflamm, REd or w/o inflamm, WHITEHEAD nodule, over 1.5cm papule under 0.5 cm |
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acne
rf |
RF
Meds: OCP, lithium, INH, pheny, halogen meds, steroids systemic genes oil, job at grill NOT RF: stress, diet +/- sun |
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acne
rx |
1. assess adherence 1 month to OTC benz peroxide 5-10% (efficacy not dose reltd), improves desquam and antibacterial. open comedones/blackheads and whiteheads, contact derm in some.
2. salicylic acid: OTC 0.5% or 2%., whiteheads, pustular acne, inc cell turnover, NO antimicrob axn 3. top abx = systemic but cant get topical on back. Tetra bad for pregnant people but antimicro and antiinflamm.. Skin peeling. 4. top retinoids/tretinoin: peeling, good for closed comedones, whiteheads. stops new acne not treatment of current ones. Use at night, sun hypersens. TAkes 3 weeks. 5. retinaA: lab draws for lipids. Use if fail others and scarring nodulocystic. |
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acne
diff dx rosacea |
rosacea
flushing, telange, central face no comedones perioral dernatitis: papules, use top steroids on face |
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prev includes
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immuniz
meds: HRT, ASA screening : CA education healthy behaviors |
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prev
woman age 22 |
TF ages 18-24
pap q3yrs DPT q10 yrs chlam test Q2 yrs HTN Q2 yrs |
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prev
wmn age 30 |
TF ages 25-39
pap q3yr DPT HTN q2 |
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prev
wmn age 45 |
TF ages 40-49
* MAMMO Q1-2 yrs starting age 40 pap Q3 DPT HTN Q2 |
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prev
wmn age 55 |
TF age 51-65
pap Q3 DP T flu vax starting 51 mammo (start age 40) ** colon cancer starts age 51 |
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prev wmn age 68
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TF age 66-70
* PNA vax once flu yearly (age 51+) DPT mammo Q1-2 (start 40) colon cancer starts 51 ** osteoporosis screen age 60, DEXA 65 |
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prev wmn age 74
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TF
age 71+ flu colon cancer until age 75 mammo Q1-2yr osteo screen |
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prev men
25 |
TF men 21-34
HTN Q2yr DPT |
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prev men age 40
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TF men age 35-49
HTN Q2 DPT ** Chol Q5 yrs starting age 35 |
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prev men 55
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TF men 50-64
*colon cancer start 51 chol Q5 starts 35 DPT * flu yearly starts 50 |
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prev men
70 |
TF men 65 - death
colon cancer until age 75 flu vax PNA vax starting age 65 DPT ** AAA if ever smoked |
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TF lifestyle type reccs
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MVI folate women daily 30 yrs
3 smoke detectors, change batt yearly bike helmet dental Q6M, yearly xray brush teeth and floss, change brush Q3M |
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TF
Insuff Evidence low risk Dont screen asymto |
Insuff ----------
dementia, DM , Drugs fam viol, oral cancer , skin cancer glaucoma, suicide, thyroid prostate CA, lung CA dont screen--------- Car art stenosis, PAD scoliosis, testisular Ca, EKG, stress echo ovarian Ca, pancreactic CA |
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prev older
stroke osteo fx |
stroke
a fib use warf control sys HTN CV: ASA after 50, control HTN osteo exercise, bal and gait training, reduced use restraits, envir mods DEXA after 65 height at every visit, loss of 2inches suggest osteo, Recc Ca 1200 mg day and 400-600mg vit D daily |
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prev oldeuntil
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older have
more automony more use CAM, OTC greater belief self eff |
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prev older
mammo pap breast exam prostate |
mammo: Q1-2 yrs until 75 then Q2-3 yrs, no upper limit if life expec over 4 yrs
pelvic: d/c over 65-70 if 3 paps nml, unless SA for STDs breast: yrly prostate: TF no DRE/PSA over age 75, often no recc Rx asympto men over age 75 |
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prev
DM screen |
Screen DM if HTN 135/80
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prev older adult
ID |
flu after 50
PNA after 65 tetanus Zoviraz once at 60 |
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prev older adult
ADLS |
DEATH
dress eat ambulate toilet hygience get-up-and-go test: get up from chair stright back, walk 10 feet, return and sit. Nml 10 secs. ~ ADLS and fall risk. |
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prev older adult
IADL |
SHAFT
shop, housekeeping, accounting, food prep, transportation |
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prev older
drug coverage |
1 stay medicare, decline drug coverage
2 stay enroll drug coverage plan 3 opt out medicare, enroll govt mgt plan with drug bene's Meidcare does not dover H&P, eyes, teeth, feet, TETANUS |
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msk
deep hip buttock pain when walk, ok when sit nml SLR, nml reflexes |
spinal stenosis - claudication
under 25% +SLR or less reflexes |
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msk
38 wmn tingle numb little finger, all of ring finger, weak flexion of fingers and wrist able to spread fingers fine |
C8 : sensory loss pinkie and ring finger
and motor loss flex wrist and fingers. Know C8 not Ulnar as interossei nml, and sens loss of ALL of ring finger not just partial. carpal tunnel would have weak apposition of thenar/hypothenar c6 is thumb and index finger. c7 middle finger sensory, narrow band ventral forearm |
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msk mgt
1. MSK pain 2. worseing night pain, no trauma |
1. NSAIDS, PT
2. MRI for cancer, esp if older breast cancer age |
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msk
whiplash |
from hyperextension
1. films exclude fx 2. spurling test: specific not sens, painwhen turn head to side of injury 3. nml to have crepitus when push larynx back against vertebra, if gone, hematoma |
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msk
55 man -less sensation radial side thumb and index finger - nml triceps reflex - diminished biceps reflex - diminished elbow flex, and supination What nerve/root ? |
c6:
biceps is c5, brachioradialis is c6 tripceps is c7 If not better, next step B4 referrral to sx is MRI. |
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msk
55 yo man with DM 2 days severe back pain in thoracic spot fever 100 WBC 16K |
Stat MRI and neurosx conslt
epidural abscess |
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msk
45 yo healthy wmn pain left hip below iliac crest 3 wks radiates down ant thigh can evert hip w/o pain nml reflex, and SLr tender distal iliac crest over prominence of hip bone |
trochanteric bursititis
inject steroids or local |
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sports cv
describe murmur of hypertropic cardiomyopathy Pulm stenosis |
A sound of S2 louder vs Pulmonic
diamond shaped murmur Louder with valsalva Quieter with squat (pulm sten louder) PS: loudest upper L sten, radiates neck and post lung fields Need R heart cath b4 sports, |
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sports
to test steroids female althlete triad |
test-to-epitestosterone ratio
triad: amenn, eating d/o,osteoporosis |
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sports
concussion |
grade 1
confused, amnesia less than 30 min, No LOC RX: can return to play if asym for 1 wk, stop if sx's again grade 2 confusion with amnesia LOC less than 5 min amnesia less than 24 hrs Rx: stop play, can return when asy for 1 wk grade 3 LOC over 5 min OR amnesia over 24 hrs Rx: stop play 1 mnth, resume if asx 1 wk of play |
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msk carpal tunnel is what nerve ?
scaphoid bone aka |
MEDIAN nerve
scaphoid bone aka carpal navicular, pa in snuffbox and when clench hands; immobilze 2 wks even if xray negative. |
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msk fight bite
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cover gram negs (past and eik)
and gram pos tetanus if needed nsaids look for 5th Metacaral |
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msk
ant dislocation hum head assoc w? |
fx post lat humerus
if no fx, check radial and ulnar pulses and neuro, then relocate |
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msk
review imaging for AC separation |
?
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msk tennis elbow
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lat epicondyle - where brachioradialis goes
over use, worse with handgrips can use glucocort |
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msk
20 yo female althlete intermitt bil knee pain after volleyball, worse sitting w/ knees flexed to study no effusion, no joint line tender, yes lat subpatellar tenderness |
patellofemoral instability
it tracks wrong and causes pain OsgoodSch wld be pain on tibial tuberosity |
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msk
common finding with ACL tear |
ACL tear:
+ ant drawer, swelling +lachman See also medial coll lig tear: medial/lat joint line tenderness * Valgus deformity with pressure applied |
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msk knee
* teen boy knee gets crushed by guy falling and knocking him over * valgus test: 10 mm opening in flex and 8 mm in extension no effusion, tender on joint line neg lachmann |
VALGUS:
bring foot out (knee in) MCL tear or MCL/ACL tear |
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same boy but varus test positive
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varus test: bring
(knee out) foot in |
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msk back
- walking shorter on one side |
- antalgic gait
shorter on bad side |
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msk back
Pain c/w sciatica and myofascial |
Sciatica: radiates low back to butt to posterolateal leg
lumbsacral N compression myofascial: worst 1 hr after awaken/sit/stoop worse with flexion/stoop - contracture |
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msk back
spondylo listhesis |
listhesis : vert moves forward on one below it
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msk back
how to do SLR per AHRQ |
Hand on knee so fully extended.
Relax leg. Hand cupped under heel, raise leg slowly. + Pain before hamstring strectched enough to move pelvis. Ask where pain is. then DORSIFLEX ANKLE -> if aggrevates or not the pain BELOW KNEE and then better when foot plantar flexion. then try internal rotation of leg-> + worse c/w sciatic nerve. Pain in other leg, more specific, less specific, radiculopathy. Looking for pain BELOW KNEE. |
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msk back What root/N
PAIN/numb: buttock down thigh and lateral leg Motor: dorsiflex foot R: Nml reflexes. |
L5
PAIN: buttock down anterior thigh and lateral leg to side of foot. NUMB: lateral shin Motor: dorsiflex great toe, dorsiflex foot Test : Cannot heel walk. R: Nml reflexes. LWW FM bk p 597 |
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msk back what nerve/R
SENS PAIN: buttock, strip down back of thigh and calf (to lat foot) NUMB: upper calf MOTOR: plantar flex of foot. Reflex: diminsh ankle jerk. |
S1
LWW FM bk p 597 SENS PAIN: buttock, strip down back of thigh and calf (to lat foot) NUMB: upper calf MOTOR: weak plantar flex great toe and plantar flex of foot. Reflex: diminsh ankle jerk. |
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msk back
S PAIN: low back, anterior thigh, front shin MOTOR: extend quad |
L4
LWW FM bk p 597 S PAIN: low back, anterior thigh, front shin S NUMB: inside thigh at knee MOTOR: extend quad R: diminsh knee jerk |
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msk back
pain still there after one month |
- no sign N root -> do EMG, if +, MRI
- signs N root -> MRI/CT is possible sx - prior sx do MRI w/ con to tell hernia vs old scar |
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msk back
pt a truck driver SX: back pain, worse when gets out of chair, limb with shorter leg/anaclitic gait PE: SLR abn, pain hip flexion, trouble extending leg when sitting, pain on anterior thigh to palpation |
Iliopsoas syndrome
Fix or get lordosis. |
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msk back
Hx: moving backs of mulch (stoop w. twisted torso) Sx: pain mid buttock or low abd or groin or SI/trochanter PE: pain to palp buttock by sacrum, and lateral by gluteal fold |
Quadratus lumorum
Top myofascial pain syndrome This m stablizes spine on pelvis and aids lateral bend. |
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msk back
unilat pain on SI joint |
R/O Ank spondy
Schrober test: 2 marks (L5) should move apart with bend Sacroiliac dysfx: manip and sx help |
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msk back
activity reccs return to work |
+grad stretch and walk early
* 2-3 wks after onset low impact 10-20' daily then increase to 45' slowly + Most jobs RTwork 2-3 days w/o lifting + Phy active jobs in 1-2 weeks: caution rotate, rest, lifting. + sitting jobs: work up from 10-20' to 60' over 1-3 months |
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msk back
physical modalities |
Manipulation : ok, stop if no help in 4 wks
PT : good "slow sit back": push self up, roll spine down table. Helps flexors abs and hips. Do TID |
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msk back
Hx: fell onto butt Sx: pain low back and down one leg to foot/tingle; painful to sit- lift one buttock up; walks with anaclitic gait PE: pain with forced int rotation of leg at hip |
PIRIFormis syndrome
Most sens test = rectal exam. # Freiberg test is another diagnostic sign that elicits pain upon forced internal rotation of the extended thigh. # The Beatty maneuver reproduces buttock pain by selectively contracting the piriformis muscle.4 The patient lies on the uninvolved side and abducts the involved thigh upward; this activates the ipsilateral piriformis muscle, which is a hip external rotator and, when the hip is flexed, an abductor. # A painful point may be present at the lateral margin of the sacrum OR over trochaeric bursa/grt trochaner/lateral buttock Exercise by cross foot over other leg, push down thigh. |
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msk back
this streches what ? |
piriformis
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msk back
this stretches what ? |
q l
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msk treatment myofascial pain
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1. Aceto, NSAIDs
2. opiods no better than non-opiod (no muscle relaxants- dont work) 3. maybe epidural injections/lido/Us trgigers, +/- evidence, try if to avoid sx |
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msk back
peds red flags |
under age 4
kids asks to skip gym etc over 4 wks fever postureal shift trunk/splints limits motion neuro change - rare root changes in kid |
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msk back
consult |
acu: chronic
masage: myofacial chiro: acute w/o radic in 1st month sx: hernia disk and nerve roots if no improve 6 wks - 8 wks. Immed for bowel/bladder, prog neuro impair. neuro: myelopathy, UMN, obscure cause PMR: no change, no red flags Anes: steroids |
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msk treatment myofascial pain
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1. Aceto, NSAIDs
2. opiods no better than non-opiod (no muscle relaxants- dont work) 3. maybe epidural injections/lido/Us trgigers, +/- evidence, try if to avoid sx |
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msk back
peds red flags |
under age 4
kids asks to skip gym etc over 4 wks fever postureal shift trunk/splints limits motion neuro change - rare root changes in kid |
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msk back
consult |
acu: chronic
masage: myofacial chiro: acute w/o radic in 1st month sx: hernia disk and nerve roots if no improve 6 wks - 8 wks. Immed for bowel/bladder, prog neuro impair. neuro: myelopathy, UMN, obscure cause PMR: no change, no red flags Anes: steroids |
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uri
adult 7 days been sick: had runny nose cough 3 days, better for day and half, then sick again. thick rhinorrhea decongestants not working teeth hurt |
sinusitis - suggest bacterial
double sickening also poor transillum facial pain w/ lean forward cough at night low smell sense unilat facial pain |
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COPD
who gets O2 |
PaO2 under 55 mmHg
55-59 but with cor pulm, pulm HTN, or high RBCs 60 with sleep apnea or desat with exercise. Suppl to paO2 of 60 or pulse ox 90% |
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COPD triage staging and when to refer
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Spiro
FEV1 > 50% -> No ABG FEV1 35-50% -> do ABG for eval of O2 need. Possible consult. FEV1 under 35% -> ABG for O2 eval -> Pulm consult. ALso consult for pulm rehab for: over 2 hx or ED visits or sx that limit function. |
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COPD nutr
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loss wt wtih nml serum albumin
suppl l carntine |
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COPD
OTC meds abx |
No cough meds
Only expect and mucolytics in acute exac. chr bronchitis in acute can get Strep PNA, Hib, Morax catar, only use abx short term. no role for prophy. |
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COPD meds
intermittent persistant |
intermittent
SA inhaler br.dilator PRN: albuterol or ipratropium persistant SA or LA br, dilator inhaler DAILY plus a SA PRN OR combo dilator+ICS (ICS does not help long term disability or death but reduces exacerbations) Inpatient for low O2 or high CO2 Can add theophylline |
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dm
5 features of metabolic syndrome |
central obesity
DM2 HTN low HDL high Trigly Others: PCOS, NASH, high uric acid, high PAF1, sleep apnea. |
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dm
gest dm 1. risk of DM2 2. screening 3. Rx 4. Goals |
1. 50-70% chance DM2 later
2. screen 1hr GTT wk 24-28 3. Rx ins and metformin (catB) 4. Goals: fasting under 90 2 hr post prandial under 120 |
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DM
macrovasc comps microvasc |
MACRO
altheroscleorosis- CAD, PVD Risk of CAD/stroke 2-4x MICRO retina, micro renal, neuropathy (hypotension, auto, tachy, gastrochesis) T1 more retina T2 more macro CVD, PVD |
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DM prevention
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DM2
1: diet, exer, metformin 2: lower bg, ACE, weight control, lipid contorl, control HTN |
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DM screening
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TF:
None asymto Screen HTN High risk: obese, fam hx, gest, other part of ins resistance syndrome ADA 45+ Q3yrs baby over 9 lbs , parent/sib DM gest, sedentary obese > 20% IBwt sp central recur candida, prior glu tol probs Parts ins resist: HTN, HDL < 35, tri > 250 |
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Dm usual presentation
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tired, weight loss due to hypergly
less common to see PU/PD polyphagia |
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DM
1. lab crit to diag 2. other labs drawn at diag |
1. CRITERIA to DIAG
* one random over 200 plus sx'a * 2 fasting over 126 * 2 2hr post prandial over 200 Any combo DEF IGT: fasting 110-126, 2 hr 140-200 2. lipid, renal (K, creat, BUN), UA for ptn, A1c Blood glu: note fingerstick 7% higher than venous blood draw. (capillary blood more art vs venous) If starting statin LFTs Occ ECG is concern silent MI occ c peptide if concern T1 vs 2. |
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DM goals for glu levels
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...........ADA Endo Assoc
fast 130 110 pprand 180 140 A1c 7 6.5 |
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DM
diet exercise |
ADA 1500-1800 cal start
to lose wt less 500 cal day than food history fat 30% with 10% less sat fats chol under 300 [ if chol/lipids an issue sat <7% chol < 200, if tri high then monounsat] [ if nephro ptn at 10%] Etoh lowers Bg salt under 2000 if HTN ------------- If microvasc - stress before exercise and prefer swimm, walk vs impact |
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DM which oral meds drop A1c the most
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metfo, sulfonuea, repaglilnide 1.5-2%
thiazolidinedione 1% acarbose 0.7-1% |
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DM oral meds effect weight and lipids ?
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metformin(neutral or dec), incretin injectible : dec weight
sulfonureas (glip), insulin, thiazolid (pioglit), meglit (repag): gain weight no change: sitegliptin , ?pramlitide, maybe metf metformin and thizolidindiones: dec TG and inc HDL slightly |
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DM meds
which cause low glucose aka cause ins secn ? which dec ins resistance ? |
Cause ins secn
sulfonureas so low BG. repag/meglit - less low BG than sulfonurea incretin but only if high BG Do not cause low BG, no ins secn metformin Dec ins resistance metformin, thiazin, Acarbose: now low BG on own, can low BG with sulf/meglit. Does not cause ins release, delays absorb sugars. |
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DM meds
Monitors metformin ? What monitors for piogliazone and rosiglitazonev ? SE acrabose ? |
Metformin: need good renal, liver, no CHF.
glitazones: LTFs before Rx and then moniter. acrbose: gas, diarr as act on brush border |
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DM new meds
pramlitide sitegliptin incretin |
8 pramlitide/amylin: slow gastric emptying, dec glucagon, dec A1c 0.5%
* sitegliptin/DPP-IV: slow GLP-1 breakdown, Doesnt delay gastric emptying, no wt loss, dec A1c 0.5-1% * incretin: injectible SQ pre meals BID, glucagon like peptide : enhanced gluc relase only if glu high. SLow gastric emptying so feel full and loss weight. |
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DM
how to start insulin |
Divide avg fasting glu by 18
Or divide body wt in kg by 10 If to low, inc by 3 unit incements every 3-4 days. Give half of needs long acting daily. |
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|
DM renal dz
|
Mainten
Goal BP under 130/80 or even 120/80 yearly urine dip alb and serum creat if abn then ACE. No EBM benefit to prophy use ACE. Values on 24 hr collect OR spot - nml < 30 mg/ 24 hr < 30 microg/mg - microalb 30-300 - clin albuminurai over 300 |
|
|
DM retina
|
yearly exam
laser for PROLIF retinopathy exudates, hemm, microanuer, neovasc |
|
|
Dm lipid goals
|
total chol under 180
Trigl under 150 HDL over 45 LDL under 100 OR says ATP-III under 70 plus daily ASA |
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|
DM meds
fasting control post prandial |
FASTing
|
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|
DM
metformin |
Metformin = biguanide
USE: 1st line obese DM2 MOA: dec fasting, dec liver glu prod, de circ ins levels Does not cause ins release, no hypogly. SE: lactic acidosis, avoid CHF, liver renal fail, hypoxia, creat over 1.4 MoniteR: LFT, creat, cbc, b12 Other Effects: neut/wt loss, dec LDL and trigly |
|
|
DM
thiazolidinedione |
= pioglitazone rosiglitazone
MOA: inc ins-recptr, dec ins resistance, dec fastng glu, dec liver glu prod, inc muscle uptake, dec circ ins levels, SE: weight GAIN SE: liver probs, edema legs Moniter: LFTs before start |
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|
DM sulfonureas
|
glipizide, chlorpropamide, tolbutamide, tolazamide, gynase, glimipride
MOA: ins secretalogues Inc insul secn -> cause hypogly, dec fasting glu, may dec ins resist SE: weight GAIN USE: ok 1st line non-obses, add on with metformin |
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|
DM
repaglinide |
a meglitinides
MOA: ins secretalogues, acts like sulfonurea, less hypogly; additive w/ sulfon and metfor, USE: post prandial control, fast onset and lasts 2 hrs |
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|
DM meds
category of pioglitazone rosiglitazone |
thiazolidinedione
|
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DM med
name a meglitinides |
= repaglinide
|
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DM meds
acarbose |
acarbose and meglitol both
a-glucosidase inhibotors MOA: act brush border inhibit complex carb breakdown, delay absorb; delay not block absorb. SE: gas, D, anemia SE: as mono no hypogly but see w/ combo |
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|
DM maintenance surveillane
|
Yearly
microalb, dilate eyes, flu vax, Q3M : A1c Each visit: feet, BP ortho |
|
|
DM how to start on insulin
|
Avg fasting glu mg/dl Divide by 18
OR divide avg body wt by 10 Start long acting daily |
|
|
HTN
when is syst vs dias bad ? define iso syst HTN ? Define pre HTN |
Syst HTN bad after age 50.
Dias bad under 50 Isolat sys HTN : over 140/under90 PreHTN: 120-139/80-89 |
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|
HTN
pt HTN high LDL |
not essential HTN
HTN as part of ins resistance Other causes/things ask HPI: estrogen meds, NSAIDS, triptans, decongest |
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|
HTN
PE signs co-arc |
Nml between arms 10mm
CoArc between R brachio - L subclav: over 10 diff CoArc above L subclav: weaker leg pulse vs arm carotid bruits= ATHeroscle |
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|
HTN eye
|
Note: cant see vessel walls just blood column. So if art thicker wall, see narrow column.
Early: art narrow (thick wall), nicking, inc light reflex off art wall LATE: hemm, copper wire(chol wall), silver wire (ca walls) |
|
|
HTN due to pri aldo
|
high Na
low K Same with Cushings: high glu, |
|
|
HTN
diet |
low Na, trial for 2 wks for response
INCREASE CA, K (positive ions/cations) |
|
|
HTN
meds diuretics |
HCTZ - thiazides, 1st line
SE: low K, worse BGlu No good if creat >2 LOOP- lasix USE: heart failure nad HTN K sparing spiro Use with HCTZ to lessen K loss, rarely used solo DIUERTIC SE: inc chol, inc Bglu, inc uric acid, tired, impotence |
|
|
lipid
xanthelasma xanthoma |
xanthelasma
xanthoma on eyelid xanthoma: yellow subdermal lipid full macrophges |
|
|
lpid
prev lipid hyper |
30-50% americans
Screen: TF men over 35, wmn 45 younger if RF CAD ATP Q5yrs after age 20 (fam hx high lipids, early cardiac death, stroke, claud, or mult RF CAD) |
|
|
lipids
diet |
3-7 day diet record
remove high fat, high chol foods can lower by 5-15% Goals - need counseling for this under 200 mg day chol ptn 15% cal sol fiber 10-15g total fat 30% cal, mono up to 20%, warm-olive peanut poly up to 10% temp corn canola sat under 7% tropical - palm, coconut |
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|
lipid
most imp part interview |
fam hx
|
|
|
lipid
what is measure what is calc |
measure
total, TG, HDL CALC LDL: total=TG/5+LDL+HDL VLDL=TG/5 as long as under 400 |
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|
lipid how to get a pre-rx baseline
|
measure twice, at least week apart
fast 9-12 hours unfasted: total up by 10 pts TGs much higher |
|
|
lipids
raise lipids |
Raise LDL:
hypothy nephrotic (also TG) Raise TG Chr renal fail DM high TG low HDL OCP, thiazides, pred alcohol pregnant Drop HDL etoh, sedentary |
|
|
lipid
set pts target lipid |
Determ RF, one point each
men over 45, wn 55, or posmeno smoker HTN DM CHD relative HDL under 35 0-1 point: LDL under 160 2+ points under 130 2nd prevent/DM: under 100, or 70 Best TG under 150, high is +200 Best total under 200, high is 240 HDL under 40 is low |
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|
lipid
meds statin effects |
Dec total chol, dec LDL, dec tri
AE: GI, h/a, myalgia, Monitor LFT if pain CPK, fasting lipid |
|
|
lipid
niacin |
For increasing HDL
Effect: inc HDL, and good for all others AE: bad glu, flush, ab pain, N/V. GOUT Mon: LFT, uric acid, glu, fasting lipid |
|
|
lipid
fibrates |
gemfibrozil (gallstones)
clofibrate, fenofibrate Use: High TG over 400 Effect: drops TG, inc HDL, ** some pts can inc LDL CI: renal and hep probs AE GI h.a derm, * w. statins myalgia/rhabdo Moniter: CPK, PT/PTT/INR, fasting lipids |
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|
lipid
bile acid seqiuest |
cholestyramine colestpol
Por GI tol Effect: drop LDL, inc HDL, Rare inc TG AE: GI, interfere absorb drugs, (dig) |
|
|
lipid
diet for hdl d/o diet TG d/o |
use mono unsat fats
total fats 30% cal TG: low FAT |
|
|
lipid
pt on statin has diffuse myalgia, no fever |
stop meds (stain/ fibrate)
hydrate serum CPK UA for myoglobin/ptnuria renal profile If abn hydrate and fix lytes Prav and fluvas less myalgia than others. |
|
|
lipid
when check kids BP what about kid with high lipids |
age 3 check BP
child with high lpids: r/o 2ndry, refer, bile seq ok at age 10 Ped ranges: total 200, ldl 130, hdl 35 tg 150 |
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|
lipids
CAM |
chromium inc HDL
fish oil help art, hyper TG garlic lower LDL and TG niacin lower TG and inc HDL spy: lower LDL and TG |
|
|
HTN urgency vs emergecy
|
HTN urgency
high stage II and sx's h/a SOB epistax, anx HTN emer >180/120, acute-> end organ damage |
|
|
HTN in pts with ins syn vs NOT
|
pts ins resist if lost weight, exer may not need meds.
|
|
|
HTN
CCB |
Less metabolic SE
may inc death in some pops: heart block, worsen heart failure, h/a, constipation periph edema |
|
|
HTN
B blocker |
brspasm, bradycardia
heart failure dec CO and exer tol tired, depr impotent NOt great if young or exercising |
|
|
HTN ACE ARBs renin Inhib
|
ACE
Great DM2 and good heart failure AE: cough, HIGH K, angioedema CI renal art stenosis, preg ARBS no cough, HIGH K, angioedema renin inhibitor: aliskiren, blocks making AngI |
|
|
HTN
a blocker peripheral a agonist central labetolol |
per a blocker terazosin
BPH SE syncope, post hypo, tired central alpha blockers clonidine hydralzine methyl dopa sedate, dry mouth, tired, imp clon-rebound HTN labetolol combbo a and b blocker hard to control HTN |
|
|
HTN
AA preg |
AA: diur, CCB
Preg: methyl, beta, diur, hydralzine for emergency NO ARB/ACE |
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|
pv
prev |
prev: 25% couples, 11-22% womn primary care clinincs
phys role: abuse not norm, affects health, document injuries screen for child abuse |
|
|
pv
hx taking |
avoid: abuse, violence
say: hit, hurt, threaten, are safe, how argue AFRAID assault, fear, rape, accused (things didnt do), isolation/intimidation, degraded (name calling, dismissed needs food clothing) |
|
|
pv warning imminent danger
|
escaltion freq/severity
inc use etoh/drug either party weopan in home threat suicide either abuse kids pets |
|
|
pv preg
|
screen ea trimester
more common hep bor gest DM |
|
|
vag
prev STI teens Rx partner w/ STI CDC 5 P's |
1/4 teens get STI
W. + partner Rx women empiricly. CDC 5 P's: partener, prevent preg, protection from STIs, practices, past hx STIs |
|
|
vag
RF yeast |
DM glu control
steroid use use lower dose est in OCPs HIV |
|
|
vag
sx chemically vaginitis |
d/c wh yellow
leukkorrhea scant-> copius >10wbc/hppf, no lactobacilli inflmm may or may not be maloder |
|
|
vag
wet prep |
low power wbc rbc hyphae
high lacto, clues, trich |
|
|
vag atropic rx's
|
top need prog is have uterus
cream ring for 90days patch- les sfluc than oral oral can cz N on empty stomach |
|
|
vag
yeast inf preg |
nystain tabs
|
|
|
mental
prev Pri Prev Sec Prev |
-mental illness > HTN but under-recog
most fam exper Ment Ill - anx and dep top 10 dx fam med -Pri Prev: exer, less stress, strong self image> sleep, diet, no drugs, social support - Sec Support: not validated, meds and therapy |
|
|
mental
somatization |
- one or mult visits
- avoid stone turning - dont crit for not being stoic - somat-mental AND mental to somatic (paralysis->depr) |
|
|
mental
-cog therapy |
-examine beliefs, shift irrational beliefs , to shift behavior
|
|
|
mental
-situational anx |
- under 6M, reaction to acute event
- SI: just thoughts of death of suicide, OFTEN NOT intent/lplans |
|
|
mental
Maj Depr RF suicide |
-diag: recur episodes last 2 weeks
50% recur after one episode. - RF suicide (not just depr) few supports, mult stressors, chronic medical conditions, substance abuse, senior age |
|
|
mental
SAD |
maj depr (2 weeks) related to season
can be late spring/summer & vegatating OR winter, atypical w/ sleep, irriatble, eating, rejection sensitivity Rx: light rx>no rx; unsure whether meds or light better |
|
|
mental
bipolar |
BAD: depr and mania
dysthymia cyclo: 2 yrs many hypomania episodes w/ depr mood periods |
|
|
mental
GAD OCD PTSD social |
GAD: 6M worry concern Rx: buspirine an azapirine, non addicting
OCD: obses and comp, Rx: high dose SSRIs PTSD:incl anhedonia, anger irritable avoidance startle detachment sleep issues social/Soc Anx d/o: fear soc sit frightening/disabling |
|
|
mental
depr history taking |
abuse, meds, surgeries,somatic d/o
|
|
|
mental anx meds
|
ace-i, antidepr,
-- caffeine, decong low glu w/ insulin ---ANX and DEPR dronabinol, digoxin, steroids, stimulents |
|
|
mental depr meds
|
Depr
alpha blockers, cancer meds, seizure meds, disopyramide, antihistamine, hydralazine, levodopa, metoclopromide, OCPs, procainimide ------ barbs, benzos, beta blockers, medrozyprogest, narcs reserpine ---ANX and DEPR dronabinol, digoxin, steroids, stimulents |
|
|
mental
thyroid test ? |
TSH hypothy -> silent hypo looks just like depr but depr goes away wiht treatment
thyroxine for hyperthy |
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|
mental
antidepr meds |
wait 2-3wks b4 change dose.
2M for max effect. refer by 3M if not better. proxac ahs one weekly drug -TCAS: worse prostate hyper, constipation, hypotension, tacycardia, antichol, tremor, weight gain - SRRI: same effect, less SE, long sex SE but others go away, N/D h/a agitation insom/sleepy -MAOi: diet limits, drug-drug |
|
|
mental
bipolar |
mood stable first, if also depr can add anti-depr
- stable: carb (check levels, check blood count for bone marrow supression) gabapentin, lithium - check thy and renal and levels olazapine: risk tard dysk valproic acid: levels nad LFTs aripiprazole: tard dysk - 2nd line stable: topamx, tiagabine, lamotrigine |
|
|
mental
kids senior preg CAM |
kids: need higher dose anti-psych, abuse can have same sx's as mental illness
Elderly: SA more successgul. Rx depr can help dementia. Use lower dose SSRI. preg: SSRI ok, no stablizer when breastfeeding CAM: st joh 300 mg TID |
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|
obese
weight classification |
over wt bmi 25, 65% adults
obese 30 - class 1 30-35 - class 2 35-40 over 40 / class 3/ extreme obesity extreme 15% Afr Amer women Waist: over 40 men , over 35 womn |
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|
sinus
etiol Define persist vs recurrnet |
#1 viral
#2 bact: usually pos viral URI - Strep PNA - H inf - Morax CAtarr (occ psudo, gr a strep, staph, anen, fungi) Persist = after 21-28 days abx Recurr: 3/more x year |
|
|
sinus
rhinititis def |
INFLAMMATiON not infecton
allergic infectious medicoamentosa oocuap: chemical vasomotor: no ientifiable allergen |
|
|
sinus
films for recurrnetl |
*water view
ap view face nose raised 2-3 inches, chinon film ONLY for MAX sinusitis *recurrent: nasal cytology for eos, immunodef studies: ig types, hivtootal complemtn, complement *films: CT=4 views films in cost Signs film: mucosal thick, loss air space vol max sinus, opac or air fluid volumes |
|
|
sinus anat adult vs kid
|
adults:
max, ethmoid KIDS: get max 1st (0-12M) ethmoid * sinusitis sphenoid * 4yrs old |
|
|
sinus rx
|
amoxi 5-7 day. if not clear 14 days.
may take 8 wks treatment if chronic. irragation, saline. decongeatants. steam ** NO anthistamine as these THICKEN mucus. Ok after resolves if have hay fever. |
|
|
ha
aura ? |
20--30% have aura
-fortification spectrum = jagged bright lines assoc w. visual migraine - scotoma: black spot visual field assoc migaine aura |
|
|
ha
cluster |
not familial
|
|
|
ha temp arteritis
|
inc ESR
|
|
|
ha
dont imaging |
prior identical ha
nml vitals no acute neuro abn supple neck alert cog intact imorovemtn w/o meds |
|
|
ha daily, worse am, N, abd sx's, insomnia, resltelss, down, poor memory, hard concentrate
|
rebound, now taking med daily
|
|
|
ha
blur vision, sudden, N/V tearing worse wit stress |
acute angle glaucome sarted antichol med
|
|
|
ha ci triptans, ergotamine, DHE
|
ischmic heart dz: angina, prior mi, silent ischemia, printzmetals
unont HTN, prior stroke, epilepsy, preg, raynauds, comp migraine (neuro deficit) |
|
|
geri
IADLs |
phone, travel, shop, make meal, housework, take meds, finances
|
|
|
geri ADL
|
physical ADLs
bath, dress, grrom, toileting, continence, transferring, walk, eat SCale Indenpend, Assist, depend Screenin functional problems simplfied: hear, vision, arm: touch back head and pick up spoon, fail -> OT leg: get up and gom in under 20 sec and reach test (9-19 inches), fail -> PT |
|
|
geri
MSE Mood Asssessment |
MSE
Folstein, MoCa(cube, clock, name, recall,attn, oreint) time place orienation, regiatration, attn calc, recall , language, comrehension, read, write, visiospatial Mood Assessment Depression Scale satified life, int activities/hobbie, qual life, boredom, spirit, fear, happy, outside activity, memory, desire live, worthiness, energy, life sit, view others |
|
|
geri
warning signs live alone |
any one
not eat right, personal hygiene, not dress for day, meds mistakes, housekeeping poor, falls or cant ambulate w/o aid, security concern/vulnerable, mental issues (fear, depr, agitat, calling 911/family alot), less independant wit finance/laundry/shop , lacks socialization |
|
|
geri
PT |
PT : Ms Phd
prevent loss mobility, reduce pain, restore function,. gait, funct mobility, balance, posture, therpay exercise strengthen, neuromusc re train, wound care, leg injury, MSK injury, transfers |
|
|
geri OT
|
BS or phd
ADL, adaptive equipment, cognition safety, FINE MOTOR, splinting, arm function visual perception, eval home |
|
|
geri speech
|
dysphageia, augmentation, cognition, voice
|
|
|
geri all
|
behavior, inhibit casting (OT), family ed, recc d/c, strenthen and endurence
|
|
|
asthma
sx's 2x week, under 1x day night time 3x month FEV1 85% predicted |
mild persistant
more than 2x month, under 1x day night time under 2x week FEV at least 80% no peak flow Use inhaled steroids say most- budesonide or cromolyn. |
|
|
asthma
daily wheeze night time 3x week |
mod persist
|
|
|
asthma
dialy sx's night time 4x week use pred 3x year |
severe persist
|
|
|
asthma Peak flow
|
gender, age, height
|
|
|
asthma
SE corticosteroids |
thrush, dysphonia,
o\possible growth , bone demineral, early cataract |
|
|
asthma
exercise |
PRN albuterol
OR perexercise albut or cromolyn \wors 5-10 min after stop |
|
|
asthma
leukotrien meds: mast cell: |
leukotrien meds: montelukast
mast cell: cromolyn |
|
|
eye
chalazon |
* chalazon: focal lid swelling
mebomioin gland compresses, topical abx * diffuse lid swelling cellilitis: IV ax and srugery |
|
|
eye
orbital cellulitis |
ptoposis
pain , dec vision, EOmvts abn, bad pupil reflex as optic N swelling |
|
|
eye
corneal abrasion |
* trauma FB, -> topical abx, ppolytrim, daily f/u
* complicated/infection -> infilatrate, lens wearere refer DEC VISION REFER |
|
|
eye h/a
phtophobia deep eye pain clicary flush: circum iris red pupil assymetry |
iriditis
pupil smaller on bad eye pain in bad eye when shine light in other eye |
|
|
svere eye pain
N/V, h/a, light halos, dilated pupil, hazy cornea, |
acute angle glaucoma
high IOP |
|
|
derm
non florinated/halogenated |
hydrocort, elocon, westcort
Better for face, groin, baby. SE: telang, candida atrophy, stria, delay healing, discolor, HPA supress, grow retard, HTN, ICP, glaucoma, cataracts |
|
|
derm
ezcema |
10% children. igE
perioral sparning, dennies (folds lowerlids), palmar markings As age: FLEXOR creases. Many outgrow with puberty. Pri Prev: breast milk, no cow milk beef until 6M, no smoke, no day care until 2Yrs. Sec Prev: bath, irritant avoidance Rx ASA, moisture, cetaphil, avveno, More severe: opt streroids. 2nd line: immunomodulators tacro/picrolimus, ok for face, intertirginous w/o risk atrophy if over age 2. Do NOT use oral steroids. |
|
|
derm aka neuroderm
|
lichen simplex chronicus
lichenified, skin colored. SEVERE itching back beck, top foot linear Rx steroid cream |
|
|
derm
erosion: ulcer: fissure : |
rash
erosion: to epidemis ulcer: to dermis fissure : to dermis |
|
|
derm
Rx wet itching |
benadryl, atarax,
domoboro/astringent: Alum sulfate and Ca acetate |
|
|
derm
Rx dry itching |
eucerin, aveeno, alpha-keri, less baths
|
|
|
derm
dyshydriosis rx? |
topical steroids
papulovesicual, between finger, soles, palms. Mild-sev itching. RF: dermatitis-atopic, contact, ring worm |
|
|
derm psoriasis
|
silver scales
Auspitz sign: pick and pinpoint red bleeding EXTENSOR (vs ecema FLEXOR) Rx: steroids, tar, PUVA, mtx |
|
|
derm
lichen planus |
polygonal purple shiny, if place oil on it white lacy pattern.
Post TRAUMA, minimal scaling vs psoriais, linear at wrist. Occ oral or genitalia. SEVERE ITCHING. Poor Rx, try topical steroids. |
|
|
derm
pityros |
nonrx, wait 6-12 weeks.
|
|
|
derm
pemphigus vulgaris |
Etiol: AI acantholysis to auto-ab
DecS: oral-> face, trunk, Symmetric. Nikolsky: rub nml skin and then get blister. EASILY BROKEN. rx: pred and gold, can be fatal |
|
|
derm
bullous pemphigoid |
bulla on red base, FLexural or intertrigonous
Rx: oral steroids |
|
|
derm
derm herpeti |
symm groups vesicles scalp and butt,
wide spread IgA |
|
|
derm
blister after minimal trama |
epidermolyis bullosa
|
|
|
derm
erythema multiforme |
acute inflamm vascular
bug, drug, chem, systemic TARGET, symm. Can be mucus mmb If severe steroids NOT erythme chronicum migrans w/ lyme- central clearing and arthriris |
|
|
derm eryth nodosum
|
shin, subQ fat inflamm
tender and red nodule : TB , med, blasto, lupus |
|
|
derm
palp purp petiche |
mening, rocky tn, cancidan, strep, HSP
|
|
|
derm
brown to groin |
erythasma
corynebacterium minutissimum woods light coral red, RF DM obese, minimal itching |
|
|
derm drug rxn rash
|
morbilliform
trunk out, symm, no palms/sole supportive |
|
|
derm ID
|
*measles: starts at hairline, drips down, koplick
* rubella: adenopathy * rosella infantum: fever but look well, rash after fever * ethy infectiousum: 5th, parvo, slapped cheek *coxsakcie: hand foot mouth |
|
|
derm bugs
|
chigger: redbug, harvest mite, bad itch at edge of clothes, burrows solution, antiitch
fleas: rxn to bite, burrows soln, anti itch scabies: belt line, excorations, permetrin, lindane |
|
|
derm kawasaki
|
Rx ASA mucocut LN syndrome, myocard, liver, renal, risk cor Art
|
|
|
derm tinea's
|
* t capitis: if kerion 4- wks griseo, keton
* t pedia: topical, #1 dermatophyte infection. 4wk rx * t versicolor** pitysporum furfur, borwn, hypopig in summer, Selsun, antifungals t cruris: ventilate clothes, powders, sharp border not on scrotum (VS candida: on scrotum, indefinate borders) Both +KOH, 2-3 wk rx, Tinea capitus recurrance #1: siblings still has it. Check fomites ! Need oral meds: non local body, nails, hair, immunocomp. Watch liver and interactions. treat body and jock for 2 weeks after no sx's, topical ok. Once start rx can go to school. GRiseo: daily with fatty meal for 4-6 wks for 2 weeks after lesion gone. Terbin: shorter course. M canis: green under lamp, longer rx. Kerions: antistaph abx, oral pred, f/u |
|
|
derm
blasto leprosy |
B : warty growth, pustules
L: waxy, no sensation, dapsone |
|
|
derm
vitiligo cholasma halo nevus |
V: PUVA psoralen
C: depigment with hydroquinone Lentigines: reina A, hydrquinone halo nevus: gone on own |
|
|
derm
discoid lupus |
AI sharp demarc, center plaque /hyperkeratotic, atrophic, cheek.
Often with telangiectasia. Not itchy usually. hypo/per pigment. VS systemic lupus, malar red and alopecia |
|
|
derm
sclerodemra localized sarcoid dermatomyositis |
slcro: white plaques, thick skin,
sarcoid: eryht nodosum, waxy face papules, eyelid, nares d: gottens papules: knuckes, Rx oral c seorid |
|
|
derm
papular circ or semi circ flesh colored back o fhands or feet ventral arms and legs doesnt itch/minimal |
granuloma annulare
|
|
|
derm
steroid potency |
steorid type I>V
conc vehicle (lotion < cream< gel< oint) area applied to Absorbtion more with: prolonged use, lg area skin damage, occlusion Classify based on vascoconst assay. Cream: pt prefer. Lotion: hairy spot Gel: stick but irriate inflamed area Oint greasy, stick well and moisture for dry scaly lesion. |
|
|
derm abx
|
1g cephalo : cephalexin
dicloxacillin mucopiricin less severe EZCEMA: bx r/o MRSA |
|
|
derm
preg - fungal - scabies - antihist |
-fungal: all C, try topical
- scabies: sulfur - loratidine, cetirizine |
|
|
derm child scabies
|
NO lindane infant
under 2M sulfur ointment, 6% for 3 nights. Over that permetrin |
|
|
derm CAM
|
primrose oil, chamomile, witch hazel, jewelweed impatiens
|
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derm contact derm
|
irritant mroe common than allergic
Patch: True Pos allergic dermatitis = itching, vesicle, rash lasting over 24 hrs, rash extends beyond site of application |
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|
derm
when oral rx poisen ivy |
over 25% body
severe itching blistering face hands genitals 60mg/day adults 1-2mg/kg kids give at least 10 days |
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derm scabies
|
treat all house and sittes
DRYER bag for 10-14 days For naive it caan take 10-30 to gets sensitized to get itch VS days RX - child over 2M old lotion head to soles - adol: neck down esp intertrig, nail, butt cleft, gentials. wash off in AM (8-14hr) ALT: lindane 1%, MORE TOXIC - seizure esp young , old. ALT ivermectin PO Even if kill mite, ITCH FOR WEEKS., nodules for MONTHS. F/u 2m for rx failure exam/r/o 5% permethrin |
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obese
bmi |
weight kg
OVER height meter SQUARED under 1% have endo or 2ndry cause |
|
|
obese
kids |
*BMI over 85th at risk over weight
BMI over 95thile overweight (early sign: cross 2 ile, rapid gain) * 3/4 stay overwt as adult *Focus wt maintenance. *If stay overwt and comorbid, loss of 2-4 lbs month. 1 hr exercise/day |
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|
obese waisr circum
|
WAIST: men over 40
women over 35 lower asian, AA, mexican reltd CardioVAsc dz even if not obese SKIN fold: anthropometric, tape and calipiers for muscular w/ BMI over 25 |
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obese CA
|
colon, panc, GB
breast, uterus, cervix, prostate |
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obese exer
|
-sedentary adult 150 min/week
-FOr weight loss better is: 200-300/wk. -best sustained 30min -resist doesnt lose wt - Posibly CV assessment if over 40, and younger if DM HTN unless already had on in office visit. -kids: 1 hr day, under 2 hrs screen time day, None if under 2 yrs. |
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|
obese
wt loss goal |
10% dec body wt over 6M at rate of 1/2 - 1 per week.
deficit 500 cal/day. One lbs=3500 cal |
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|
obese
CI SE |
CI severe med illness, severe obese, eat d/o need medical help
SE: cholecystitis if loss over 2 lb week or DM, maybe ursodeoxy acid. |
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|
obese
effect low calorie high fiber carb diet |
if refined carbs
raise trigly lower hdl in some |
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obese
* effect low carb diet * veggie |
* high ptn lower insulin
less hunger, may be easier to follow as elim lots foods. * veggie: very ow fat, acceptable Not recc if high fat, low fiber and nutr |
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obese
meal replacements |
* replace: 1-2 meals frozen or liquid/creal/soup
|
|
|
obese
overall low calorie goal diet |
low calorie diet 1200-1500 cal for 18 lb wt loss over 20 weeks
Over time, more reduction in cal for contd weight loss. VERy LOW calorie: 600-800 - need app supressants and vit suppl/ - liquid sev weeks loss 10-20 lbs over 12-16 wks No better at one year. |
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obese beh mod
|
best learn in groups
higher retention, more wt loss. |
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obese
sx - when refer - outcome |
refer: bmi 40 or 35 with comps after try 6M in wt loss program.
outcome: resolve DM, HTN apnea lpids. Loss 25-44 kg/48-96 lbs , peaks at 2 yrs. Preg ok but wait 12-18M. |
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|
obese sx types
|
Band/vertical band gastroplasty
just restirctive - loss half excess body weight at 2 yrs. - MM 0.1, 5% Roux Y malabsorb and restrict, better compliance as overeat causes bad sx's. Loss 60-70% excess wt. MM 0.5 and 5% Need suppl Ca B12 iron folate RAre now bioliopanc diversion duod switch |
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obese suppl
|
Pot bad simmetics : PPE ephedra, bitter orange, country mallow, guarana, yerba mate.
No good: chromium, chitosan, guar, spirulena, butyrate, psyllim, yhimbe, st john, dandelio, theophylliine cream. DHEA, saacara May be good and safe: glucomannan, hydroxycitric acid, pyruvate, conj linoleic acid |
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obese meds
|
ALong with diet exercise
BMI over 30 OR 27 w. co morbid esp if plateu or rebound rarely addmore than 5kg to diet/exer. Rebound when stop med. Orlistat: inhibit panc lipase. block absorp fat vits, so need vit. sibutramine: NT reup inhib. Appetitie supressent. Cause inc BP and HR. CI if on SSRI or incont HTN or heart dz older app supressents: phenteramine, diethylproprion : less data LT safety Off mkt unsafe: fenflur, dexfenflur Other wt loss meds: topiramate, zonisamide, fluvoxamine, high dose bupropion, metformin, exenatide |
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|
cam
herbs that interfere with clotting |
ginkgo
garlic ginseng asa coumadin warfain |
|
|
om
myringitis omedia w/ effusion |
my: red TM w/o effusion
OME: fluid in middle ear, no sx local or systemic illness |
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|
sub
discontinuation wdrawl wernickes |
discontin: not due to toler or addiction but those can be present, avoid with taper
wdawl: sx's from subt that you are dependant on - phy or psych Wernicke: THIAMIN |
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|
sub 5 As'
|
ANTICIPATE - all vulnerable, pri prevent, guide young
ASK and revisit ASSSESS- those dependent foramt of use, comps, ACCEPT- pts ds prob, dont say you hit kid when drunk(moralize) ADVISE to stop, give reasons ASSIST- in quitting ARRANGE f/u, review relapses, (revisit assist) APPLAUD all attempts at ea visti for 2 yrs. |
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|
sub CAGE
|
1. cut down
2. people Annoyed you by critisizing drinking 3. ever felt Guilty/bad about use 4. had drink first thing in AM to steady nerves or get rid of hangover |
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sub
Signs to assess for sub abuse |
-parent complains sig beh probs in kid, assess kid and parent for subst abuse
-fam hx bipolar |
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sub TWEAK
(not in reading) |
1. How many drinks does it take to make you feel high?
2. Have close friends or relatives worried or complained about your drinking in the past year? 3. Do you sometimes take a drink in the morning when you first get up? 4. Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? 5. Do you sometimes feel the need to cut down on your drinking? The maximum score on the test is seven points, with the first two questions counting for two points each and the last three one point each. Note about question 1: If a woman responds that it takes three or more drinks to feel high, she scores two points. If she responds "less than three," she scores zero on the question. A total score of two or more on the test is an indication of harmful drinking and further evaluation is indicated. |
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sub
labs abn w/ etoh |
high ALT :ASP ratio 1.5
high PT PTT, low alb high GGT Panc: high amy lip High trigly and uric acid |
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sub
smoking cess meds - MOA, CI |
BUPROPION: antidep, CI eating d/o and seizures. SE: restless, insom, nausea,. Start 1 wk pre quit.
VARENICLINE: nic-R blocker. Caution h/o depr link suicide. Nic replace: Use 8 weeks. gum SE nausea. |
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sub
alcohol meds drug if liver fail drug if renal fail |
DISULFRAM: inhin Et dehydr. Useful those who relapse. Cause flush/N/V/h/a.CI: CAD, liver fail, pregnant, demented, HYPOTHYROID
NALOXONE: reduces relapse. CI pts on opiods, in acute withdrawl, hepatitis or liver failure. ACAMPROSATE: maintain abstan. Reduces discomfort. CI: RENAL impairment, watch for depr.suicide Drug liver fail: acamp drug renal: naloxone, disulfram |
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|
otc
expire |
2-3 yrs post manufacture
DOD: 90% good at 5 yrs except insulin, nitro, reconst antibiotics |
|
|
otc
diarr (text: 3 loose stools day) kaopectate pepto |
Was attapulgite: water absorber, kids over 6, non-systemic, preg CI: bloody. mucus.
ACtion: dec # stools, harden Bismuth subsalicylate: Pepto antisecretory E Coli, anti-inflamm CI: kids fever flu c pox Reyes, preg, renal failure, ASA allergy |
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|
otc
diarr cause warning sign |
Causes: acarbose, SSRI, abx, dieur, PPI, thyroxine.
Warn: high fever, blood, over 3 days, eld, IC, severe abd pain |
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|
otc diarr
loperimide polycarbophil |
LOPER:
slow motility. Useful IBS CI fever, bloody mucus, (on abx, h/o liver dz) POLY: absorbs water like gel. |
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|
otc
consti def |
medical:
"unsatif defecation fro infreq stool or diff stooling" -12 weeks of 12M ROME III - strain or lumpy 1/4 stools - sense incomplete evac or bloackage - manual manuver - under 3x week Nml stool 3x day to 3x week. ROME vs Doctor: ONLY 26% meeting Rome poop under 3x weeks. VS patient: under 1x day, hard stool |
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|
otc consti causes
|
med:verap, narc, antichol, TCA, diur, antacid, clonidine, l dopa, laxtive abuse
Endo: hypothy, DM Neuro MS Park paraplegia CV sclero amyloid preg, diet/exer low obst |
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|
otc const w/u
|
*DRE
*colonscope: anor, wt loss 10#, anemia, new after age 50, blood stool *warning: fever, N/V, IBs, cancer, old * Lab thy, Abd, CBC, DRE guiac, scope No red flags use OTC treatment, lifestyle, fiber (psyllium, beta glucan oat), laxatives. |
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|
otc consti
bulking lax |
high fiber absorb water
SE bloat, fluid overload, impaction psyllium metamucil citracel methylcelluolse benefiber guar gum fiber sure inulin polycarbophil |
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|
otc consti
osmotic lax |
draw fluid in
mag salt: MOM, sodium phos (fleets enema), CI renal failure lactulose, sorbitol, PEG SE: bloat, gas, cramp |
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|
otc const
stim lax |
alter mucosal perm, can addit and kill neurons
biscodoyl dulcolax senna, casara/senokot |
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|
otc consti
supposotory |
glycerin, biscodoyl
can irritate |
|
|
otc consti
stool softener |
Need lots fluids
DEc surface tension, inc bulk, allow fat and water to mix. binds bile salts. Colace/docusate mineal oil if not aspiration risk/demated and not pregnant. |
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|
biscodoyl is ?
|
stimulent
|
|
|
docusate is
|
stool softener
|
|
|
methylcellulose is
|
bulking
|
|
|
peg
|
osmotic
|
|
|
lactulose
|
osmotic
|
|
|
guar
inulin |
bulking
|
|
|
senna casara
|
stimulent
|
|
|
otc
enema and SE |
phosphate, water, min oil, soap
SE trauma, HYPER PHOSPHATEMIA |
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|
herb
bad preg |
hormonal: black cohosh, sawpalmetto
echinecea kava st john (also not for kids) |
|
|
herb
bad heart |
aconite, ephedra, licorice
avoid ginseng low bp with black cohosh |
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|
herb
bad liver |
** KAVA 25 cases severe liver toxicity
echinacea hepatitis pennyroyal, comfrey, bush tea, chapparral, germander, celandine, jin bu juan, SENNA, skullcap-VALERIAN Lipokinetics- has yohimbine |
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|
herb
bad neuro |
aconite, ephedra (stroke, seizure)
pennyroyal (also bad liver) ST john with SSRI-> Sero syndrome VAlerian & kava additive with seds-hyp h/a ginkgo and soy |
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|
herb
nephotox |
aristochic acid = mu tong
aescin = horse chestnut seed |
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|
herb bad diabetes
|
ginseng and DM meds -> hypogly
|
|
|
herb bad bleeding
|
feverfew, garlic (anti-plt), ginger, ginkgo
ginseng + warfarin |
|
|
herb
black cohosh |
Useful hot flashes
Takes 5 weeks to work. dont use over 6M. SE GI upset, hypotension. CI preg-> miscarry. Also soy, short term, modest effect for only 6 weeks. food safer than isoflavones. SE: constip, bloat, N, allergy. Not tested:chaste tree berry, dong quai, ginseng, even primrose oil, motherwort, red clover, licorice. |
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|
herb
saw palmetto |
BPH: works ST, less good vs finasteride.
SE: ha, gi upset, diarr. False + on PSA. |
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|
herb
garlic |
Sterm bene lipid and anti=plt
SE: stomach upset. Stop 7 days pre-surg as anti-plt -> bleed. |
|
|
herb ginseng
|
Effects dementia, intermitt claudication.
Less good mem loss, tinnitus SE: gi upset,h/a, allergy on skin |
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|
herb
st johns |
depr use hypericin extract
SE: dry mouth, dizzy, consti, photosen CI: preg, child, lactate Interacts to cause sero synd: SSRI, MAO, Interacts p450 up-reg: decreases DIGOXIN, AIDS prot inhib, OCPs, thephylline, WARFARIN |
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|
herb
ephedra |
SE: HTN tachy, palps, MI, death.
Worse with symmimetics. Digoxin, guanethidine, MAO. |
|
|
herb
echinacea |
interacts immunusupre > dec action.
stop 3 wks pre-op |
|
|
herb
OA |
mild-mod OA
Takes 5 weeks to work. glucosamine: **RAISE GLU IN DM, from FISH chondroitin: from shark/cows, mad cow or metals SE:GI upset, heartburn/N/ ALLERGY SHELL FISH |
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|
otc regs for meds otc
|
1938 fda drugs safe pre-marketing
1970 package insert 1972 FDA also OTC 1994 diet suppl health and educ act: suppl are food, no need to register, prove safety or efficacy. |
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|
prev
when screne for depr |
adol 12-18
|
|
|
vax
vax age 4-6 |
dtap #5
polio #4 mmr #2 (varicella #2) |
|
|
vax type hep b
|
3 dose (4 if combo)
fraction inactive IM Who: ewnborn, adol, travel, liver dz, dialysis born 2m 6m-2yr CI: yeast allgy 100% effective |
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|
vax rota
|
2 dose 2m 4m
|
|
|
vax dtap
|
5 doses last at 4 yrs
Then age 11-12 booster TdaP if not had it yet. 2m, 4m, 6m, 15-18m, 5 yrs. IM fractional inactv toxoid risk pertu enceph |
|
|
vax hib
|
Kids under 5
3-4 doses 2m, 4, (6m), 15m, conj fractional polysacc |
|
|
vax pneuma
|
Either SC/IM
Under 2 but over 6 wks: PCV conjugate polysacc fractional - all kids 4 doses: 2,4,6,12M - at least one dose kids under 5 Over 2yrs sick, re-vax with polysacc PPSV |
|
|
vax flu
|
fract inactiv IM
Over 6M up to 18 yearly. Nasal if over 2 under 50, not pregnant. CI egg allgy |
|
|
vax MMR
|
live subQ
Must be over 1 yr. 2 doses 1 yr 4 yr LAsts 17 yrs, SE fever rash OK HIV cd>200 |
|
|
vax hepA
|
whole inactiv IM
2 dose 1 yr 2 yr (3 in combo) highest prev native Amer, lowest Asians Who: liver dz, blood d/o, monkeys, travel, risky behav |
|
|
vax meningitis
|
MENACTRA MCV4
fractional poly conj w/ diptheria, IM Syllabus: 11yr-55yr CDC: 2-55 All at 11-12, college dorms 2-11 no spleen etc. CI: prior GBS Menomune MPSV subQ under 2 (11), over 55 |
|
|
vax polio
|
whole inactive 4 doses
2,4,6-18m,4yr |
|
|
vax hpv
|
fract inacti toxoid VLPs IM
3 dose $360 Who: 11-12, 13-18 catchup, less data 18-26 Myth: ok preg, no need pap or testing 95% effective,better natural inf |
|
|
vax zoster
|
live atten subq
60-69 best efficacy - dec 50% zoster, dec 40% neuralgia - use before get zoster - Risk giving c pox CI: it is live - preg, tb, aids, pred,leul ALL neomycin |
|
|
vax tdap
|
IM fractional
tet, diptheria is toxin in formalin, 5 pertussis proteins One time 19-64 age 11-12 If unvax: give Tdap, dt, dt SE: arthus |
|
|
vax IM vs subQ
|
IM: tetanus, hepB and A, flu, HPV, manactra
SC: MMR, varicella + zoster, menomune Either: penumococcal |
|
|
vax varicella
|
live atten subQ
2 dose: 1 yr, 4 yr Who: born post 1986, health care, relative IC, teacher, CI: preg, ALL neomycin, geltain, IC, TB AE: 1% local pox, 4% mild general rash, zoster 87% effective |
|
|
change
motiv interview tools |
ready change ruler
agenda chart Motiv Interviewing - import confidence ruler -decision balence score Non Direct Interventions probe priority to change explore futures -for ambiv ---double side reflect ----validate pts experience ----simple reflect -for resistance ----emph pts responsibility and choice ----simple reflecton |
|
|
change
stages of change |
precontemp
contemp prep action main and relapse |
|
|
change
will act in 6m: will act in 30 days - acted in last 6M: acted over 6M ago - |
change
will act in 6m: contempalte will act in 30 days - prep acted in last 6M: action acted over 6M ago - maintenance |
|
|
change
denial, immune to harm, no control unaware of harm unwilling to try |
PreContemplation
Do: give info of risks Motivational interviewing- pre and comtemplation, understanding, empathy not admonish/confront. - why change, what signs it is prob, have tried change b4. No: rah rahs |
|
|
change
"...but..." may do something in next 6mnths ambivalent |
contemplation
motivational interview:why now, barriers, what keeps using, what helps change now, reason to not hcange now. what are needs to change now. With resistance: empathy, thought provoking ?'s, "yes but..". , health beliefs, CBT open to info and education Do: give ideas on facts for change, Id supports for change |
|
|
change
changing brands beginning to set goals- quit date action in next 30 days |
Preparation
DO: praise, help set goals, discuss plan for change. Use CBT. discuss coping and envir strategies and behav skills. |
|
|
change
changed but under 6m |
action
Do: CBT, reenforce committment. encourage and praise. ask about sucess and difficulties. Id risks for relapse. |
|
|
change for over 6m
|
main and relapse
encourage and praise. (ask about sucess and difficulties.) support, remove cues relapse. If relaspse: motiv interview, what learned re self and process, Focus on sucess (they did quit x days), set new goals. |
|
|
change
belief model |
cult and spiritual relate to opinions on prevention and treatment and infl hleath related decisions. may be greatest influence.
Indiv act to prevent/change unhealthy behaviors IF they: -perceive suspectibility - perceive severity (above both relate to threat of dz) - peceived benefits if act - per barriers lower than action |
