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1928 Cards in this Set

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Define: Mean Corpuscular Volume (MCV)
Size of erythrocyte
Where are growth hormones secreted
Anterior pituitary gland
Define: Mean corpuscular hemoglobine
amount of hemo in each erythrocyte by weight
Give s+s of acromegaly
excessive acral growth, facial features, sweating, HA, peripheral neuropathy, decrase energy osteoarthitis, depression, galactorrhea
Define: mean corpuscular hemoglobin concentration
concentration of hemo in each erythrocyte
Give physical exam of acromegaly
earliest most common: facial puffiness, broad nose, furrow brow, skin thickening
Define: Hemoglobin electrophoresis
% of different types of hemo in erythrocytes
What is the Diagnostic for acromegaly
Definitive test is the oral glucose tolerance test: GH secretion should be suppressed by oral glucose load
Obtain Serum ferritin determination to:
ID depletion of iron in body
Define transferring saturation and disease which it might be abnormal:
% transferring saturated w Fe
acute hemorrhage, sideroblastic, anemia, IDA, thalassemia
Acromegaly and patient education
life long chronic progressive disease, physical changes don't remit w/ therapy. But may slow down or stop just cant reverse.
When may you find a abnormal neutrophil count ie >than 0
myeloproliferative disorders, hematopoietic disorders, hemolysis, infection, immune deficient
What is Total Iron binding capacity (TIBC) and when might you find it abnormal?
amount of Fe in serum plus amount of transferring available in serum
IDA: TIBC: High due to low Fe we have high capacity low Fe
ACD: Low: less transferrin (more ferritin)
Addisons (adrenal gland disorder): define
destruction or reduction in adrenal gland
When do expect to see a rise in lymphocyte
infection lymphocytosis, mononucleosis, anemias, leukemia, hodgkins
S+S of Addison disease
N/V, hypotension, acute shock (trauma or illness). Chronic: n/v, dizzy, chronic abd pain, hyperpigment, lethargy weakness
When would you see an abnormal plasma cell count
mononucleosis, monocytic leukemia, plasma cell leukemia
PE how do patients with addison look
chronically ill, dehydrated
What diagnostic test are needed for Addison disease
Elevated ACTH and suppressed cortisol, hyponatremia, hypercalemia (CMP), CXray (exclude TB)
plasma cell count
mononucleosis, monocytic leukemia, plasma cell leukemia
Management of Addison disease (chronic)
oral hydrocortisone 20-30mg/d (restore diurnal pattern) and fludrocortisone (0.05-0.2mg/d) correct renal and hypotension.
Describe Erythropoietin patho
secreted by kidney response to tissue hypoxia--> increase production of RBC
What is the management of acute adrenal insufficiency
IV hydrocortisone 100mg q 6hr for 24hr then taper. hypotension, hypovolemia, hypoglycemia ICU
Neutrophil should be the same as adults at what age
same as adults by 2 wks
What is patient education of Addison Disease
med adjust w/ fever and common illness (hydrocortison doubled quickly) never stop steroids quickly
when do eosinophil and monocytes reach the level of adults in the body?
high first year same as adult by 1 yr
Define Cushings (basic)
Over production of cortisol (adrenal disease)
What are characteristics of RBC: deficient B12 or folate
macrocytic-normochromic anemaia (megoblastic)
What are S+S of chronic changes of Cushings disease
weight loss, loss of menses, libido, depression ,insomnia, bruising
pernicious anemai most commonly due to
B12 deficient: typcially chronic gastritis (DM1, thryroid, graves, myasthenai gravis, alcohol, h. pylori)
What do you find on PE of Cushings disease
exogenous/central obesity, moon face, thickening facial fat, buffalo hump
Discuss folate
Macrocytic-normochromic
Vit B for erythrocyte production, absorbedin upper intestin
What diagnostic do you perform for Cushings
24hr urine cortisol levels repeated 2-3x
Sx of deficient folate
Macrocytic-normochromic
scales, fissures in lips, corners of mouth , stomatitis, sores ulceration of buccal and tounge swelling
What is the management of Cushings
Depends on source of hypercortisolism: pituitary resection, Chemo,
Most common anemia and cause
also microcytic -hypochromic
iron deficient: diet, ASA, NSAID, GI surgery, pica craving
What do you find on PE of pheochromocytoma:
HTN >170systolic, arrythmias, tachy or brady
Sideroblastic anemia (SA) are rare: Symptoms include
microcytic-hypochromic
Sx: iron overload erythropoietic hemochromatosis = splenomegly and hepatomegaly
Initial eval of alcoholic would include what
CAGE
Aplasic anemia (AA) cell type
normocytic-normochromic anemia
What part of an alcoholics life is usually affect last between family, health, realtionships, work.
Work is affected last
Define Aplastic Anemia: normocytic-Normochromic and risk associated w/ disorder
absence of all three blood cells, rapid progression high risk of death form infection, bleedin, ulceration fo mouth pharynx
What are the 5 stages of Prochaska's change framework
1. Precontemplation: not interested in change
2. contemplation: consider change & pos/neg aspects
3. Preparation: makes some change to behaviors or thoughts but feeling of no tools to proceed
4. action: ready to make change
5. maintenance/relaps: learns to continue the change and deal w/ backsliding
Anemia of Chronic Disease (ACD) cell type?
normoctyic -normochromic anemia
What are the 3 steps for alcohol screening according to NIH
1. ask about use
2 assess for alcohol problems
3. advise appropriate action
4. monitor patient progress
ACD (anemia of chronic disease) may be caused by:
AIDS, RA, SLE, malaria, Hepatitis, CHF: patho: decrease life span, suppressed erythropoietin, Fe metabloism
How soon after stopping do alcohol w/ drawals begin, and peak.
begin in 12 hrs after last drink and peak 24-48hrs w/ abatement over few days.
ACD (anemia of chronic disease) Evaluation
unable to repsond to Fe replacement, low TIBC, high serum ferritin
What are sx of alcohol w/drawal
agitation, hallucination , disorientation, seizures
Anemia Hemaglobin values
<14 male, < 12 female, no sx till < 6 in healthy adult
What medication is useful for alcohol w/drawals:
benzodiazepines: ativan.
also tx dehydration, malnourishment, infection
Anemia: sx
fatigue, malaise, dyspnea decrease exercise tolerance
What are some inpatient detox criteria for the alcoholic?
other acute illness (infection, cardiac), alcohol related sx prior to detox, prior w/drawal sx of delirium tremors or seizures, coexisting mental health like depression
Anemia: sx
wide pulse pressure, midsystolic murmur, brittle nails, cheilitis, atrophy o ftongue, spoon shaped nails, pallor
What benzodazapine should be used on an alcoholic w/ hepatic dysfunction
lorazepam (or other short acting)
if no hepatic deficiency then valium
Anemia: Diagnostic
CBC w/ platlet, RBC morphology, periphera smear, reticulocyte count (decrease production or increase loss)
What role do antipsychotic play in managing w/drawal of alcohol
no role, they are not used in alcohol w/drawals
What does changes in reticulocyte mean for Anemia Diagnostic test results?
>100 normal responding marrow to anemia
<75 impaired RBC production, low reticulocyte count
MCV most useful to ID reticulcytosis or decrease reticulocyte count
What medication is used for the physical sx of alcohol w/drawal such as tachycardia or tremors?
beta blocker (propanolol, atenolol)
Anemia: norms of Serum Fe males and females
40-150 for males and 40-160 for females
What do you use for nutritional deficencies in alcoholics
high dose B vitamin and supplement of thiamine, pyridoxine, folic acid and vit C
RBC size anemia: list disease with Microcytic (MCV <80)
Fe deficiency, thalassemai, ACD, sideroblastic
Which is more specific for hepatic damage: ALT or AST
ALT: more specific to liver due to limited concentration in other organs. U should ID the ration of AST/ALT in alcoholics
RBC size: list disease w/ Macrocytic (MCV >100)
Megaloblastic andema (B12 and folate deficent)
How many criteria must be met diagnose substance abuse?
three of the following:
-tolerance (need for increase intake to produce same result)
-Withdrawal (substance needed to stop w/drawal sx)
-use amount or duration of use greater than intended
-repeat attempts to stop w/o success
-to much time spent using, recovering or trying to obtain
-reducing or abandoning social, occupation, rec activities due to use
-cont use despite knowing it causes problems
RBC size: list disease w/ normocytic (MCV 80-99)
sicle cell, anemia, chronic disease, aplastic anemia, hemplytic anemias
Who have higher rates of misuse of prescription medication? men or women
women: thought to be due to higher use of health system
Discuss causes of Microcytic anemia
most common, GI or menorrhagia blood loss, IDA , need 15mg/day Fe or 30mg/d if pregnant. Fe absorbed in duodenum
Which benzodiazapine has a higher abuse potential: short or long acting
rapid-onset or as needed basis increase abuse potential.
Discuss microcytic anemia Sx/PE
Fe store depletion, parestesia, sore tongue brittle nails (koilonychias) Pica, pallor of conjunctiva
Name on benzodiazapine that has long half life and slow onset...which also decreases risk of dependence
clonazepam
What is the first dosing step to discontinue benzodiapine in a patient that is psycholigically dependent
reduce dose by 25% per week.
Microcytic anemia: diagnostic
fall in feriting level --> Fe depletion, first change is decrease hemoglobin
How quickly does the onset of w/drawals begin with benzos
a few days w/ shorter half life (lorazepam) and up to 3 wks w. longer half life (clonazepam)
Microcytic anemia Tx
oral Fe prep: 150-200mg/d, 4-6months until serum ferritin exceeds 50mcg then stop
What are physical sx of benzo w/drawals?
HTN, tachycardia, diarrhea, nausea, hyperthermia, restlessness, myalgia, lacrimation , rhinorrhea
Fe patient education
30 minutes before meals w/ ascorbic acid (OJ) to aid absorption
What alpha-adrenergic antagonist help minimize opiod w/drawal
clonidine (also works on HTN)
Lifespan: When should you use Fe supplements. What is the best indicator of deficit
Fe supplements during prego especially last two trimesters. Ferritin level best indicator of IDA
What is a medication that is used in the tx of w/drawal of heroin but also has addictive qualities
methadone
Thalassemia patho and risk
inherited, at risk: middle east, asisan, med, africa
What are risk associated w/ chronic marijuana use
COPD, driving impairment
polycythmia vera: sx
ruddy, red face, hands feet, ears, engorgement of retinal cerebral vessels
What drug class is Rohypnol
benzodiazapines
How do you tx Polycythema vera
ASA..50% die w/in 18 m of sx if no tx
What is the DSM-IV criteria for anorexia nervosa:
inability or refusal to maintain body weight
-85% normal weight for height
-intense fear of gaining weight and becoming fat,
-perception of body weight and shape
Define Leukopenia and when you might find it
WBC <1000, > risk infection
Causes: radiation, shock, SLE, chemo
what r the 2 types of anorexia demonstrated:
restricting (intake) and no binge and binge-purge in cycles (not secretive like bulimia nervousa
Define Leukocytosis and when might you find it;
>11K, infection, exercise, surery, prego, drugs also polycythema
Treating anorexia nervosa includes both
cognitive-behavioral and pharm
During an infection cycle, when will you see Granulocytosis or neutrophilia?
in the early stages of infection
What medication can be used to increase appetite and reduce anxiety in anorexia
Cyproheptadine (Periactin): 1st gen Antihistamine
define neutorpenia
Decrease in circulating netraphils: low <2000, <500= agranulocytosis
DSM-IV criteria for bulimia nervosa
eating excessive for a discrete period w/ lack of control then binge, laxative, diuretic or fasting
Acute leukemias (ALL, AML) patho
AML: most common adult: decrease apoptosis --> splenomegaly and hepatomegaly
Sx of bulimia
hypokalemia, dental enamel erosion, parotid gland enlargement
Hodgkins lyphoma: cause
no apoptosis of B cell nor immunoglobin gene: eBV
Sx of anorexia
lanugo, dysrhythmias, hepatomegaly, cheilosis, gum disease, dry skin, hypotension w/ bradycardia, hypothermia
Non-hodgkin lymphoma: cause
too many abnormal WBC build up in spleen, bone marrow, liver resulting in cancers
What r the pharm tx of bulimia
antidepressants: SSRI
Wellbutrin should not be used may increase bingeing or seizure
Hodgkin lymphoma: sx
fever, night sweats, weakness, weight loss
What are the characteristics of binge eating and how does it differ from bulimia nervosa
lack of control over amount and type of food, at least 6 months, distress, self anger sham over amount eaten. There is no purging with this type they are usually obese
Non-hodgkin lymphoma: sx
fever, night sweats, weakness, weight loss AND pleural effusion, abd pain, spleno and hepatomegaly
Depression diagnosis typically includes:
a. early morning wakening
b. unable to fall asleep
c. hyper state
d. none
early morning wakening
hodgkins and non-hodgkins TX
radiotherapy, surgery, chemo
DSM-IV criteria for depression
5 or more sx for 2 wks:
-mood, diurnal variation (morning worse than later in day)
-interest: lack of former pleasure
-eating: increase or decrease w/ weight change
-sleep: waking at 3-4am w/ inability to fall back asleep
-motor activiy: agitated or retarted
-fatigue: lack of energy
-self-worth: inappropriate guilt
-concentration: difficulty, indecisiveness
-repeated thoughts about death or suicide
-depressed mood or decrease interest must be one of them
Thrombocytopenia definition
platelet count <100,000: decrease platelet production increase consumption
What are the difference between depression and dementia
dementia: cognitive changes slowly over years w/ depression much shorter
What leads to acquired thrombocytopenia:
viral infection, drugs, nutritional deficiency, CRF, aplastic anemia
What would u consider the dx in a person taking benzo for anxiety but feeling worse
depression
Disseminated intravascular coagualtion (DIC)
clotting and hemorrhage simultaineously occur
psychomotor agitation w/ fidgeting and irritabilty found in patients w/ depression: what age group is this found
kids and adolescents and Type A adults
DIC: Diagnostic and Tx
D-Dimer test most reliable and specific. TX: underlying causes
What are the combined approach for depression tx:
interpersonal therapy and pharm: interpersonal alone has 60% relapse
Cell description consistent w/ IDA
low MCV, low MCH or microcytic, hypochromic
Dysthmia: define
low -level daily depression w/ at least two previously ID depressive sx in 2 years (adults) 1yr (child)
Hematocrit at 23% tx w/ Fe what labs change should you see.
reticulocytosis (fitzgerald)
A change in feeling such as "feelig good to be alive for the first time" would be found in what dx
dysthmic
What happens when you take cipro and Fe together
inactivate drug compound may be formed (fitzgerald)
What is the dx of major depression (criteria)
depressed mood >3m after death or loss
What supplement prevents neural tube defect in prego
Folic acid
chronic ingestion of over cooked food make you at risk for
folate deficent anemia (fitzgerald)
what type of anemia is that?
What is the tx for adjustment disorder
interpersonal therapy
SSRI: Paxil what are the indications, A/Rxn,
: panic disorder, depression, OCD
A/Rx: sedating (HS best), constipation, antihistamine increase appetite,
comments: good if hepatic dysfunction, good in elderly due to short T1/2 life. use slow tapering to decrease w/drawal effect
pernicious anemia caused by
lack of intrinsic factor (fitzgerald)
SSRI: Zoloft: indication, adverse rxn
depression, panic, OCD:
Adverse: GI upset, sleep disturbance
comment: take w/ food to enhance absorption
SSRI: Celexa and Lexapro: indication, Adverse rxn
Depression,
Rxn: somnolence and insomnia, agitation and anorexia
comment: lexapro has better adverse rxn profile vs celexa
PE of pernicious anema
stocking glove neuropathy (fitz)
SSRI: Prozac: indication, rxn
depression, OCD, bulimia
rxn: energizing, anorexia common
comment: am dosing, long 1/2 life bad for elderly, weight loss not sustained
Asian: hbg: 9.1L, Hct 28%L, RBC 5, MCV 68L, RDW 13 = Dx
thalessemia: asian and anemic also look at RDW:
Iron Deficiency Anemia: usually presents with high RDW with low MCV
Folate and vitamin B12 deficiency anemia: usually presents with high RDW and high MCV
Recent Hemmorrhage: typical presentation is high RDW with normal MCV
What is the mechanism of action of antidepressants
increase availability of selected neurotransmitter (serotonin, norepinephrine, dopamine)
57y/o female w/ RA Hgb=10.5, Hct 33%, MCV88 = Dx
anemia of chronic disease (ACD): normal Hct: 36-46, Hem: 12-16, MCV: 80-100
How long do SSRI S/E usually last.
2-6wks,
Unilateral throbbing HA w/ difficulty chewing and tender noncompressible temporal artery
giant cell arteritis
Tricyclics: Effexor: indication, rxn
depression
stimulant in larger amounts, need trazodone to help w/ sleep, Nausea at high dose, increase dystolic by 5
comment: SSRI in low doses, dopamine effect at high dose
Tx of giant cell arteritis
systemic corticoid therapy
What antidepressant is useful in those with substance abuse too
wellbutrin (dont use in anorexia)
Most serious complication of giant cell arteritis
blindness
What are some tricyclic antidepressants
nortriptyline, desipramine
What is agnular chelitis
fissuring and cracking at corners of mouth:
caused by fungal or deficient B12 or Fe
Sx of SSRI w/drawal syndrome
dizziness, paresthesia, anxiety, nausea, sleep disturbance, insomnia
Tx of angular chelitis
nystating (fungal infection)
Serontonin activity on 5-HT1A receptor sites is used to Tx:
antidepressant, OCD, antipanic, antisocial
comment: action site basis of most antidepressant, antipanic
What causes bilaterally itchy, red eyes, tearing throughout year, rope eye discharge (think basic)
allergen
Which antidepressants should be used in place of tricyclics if there is risk of suicide
SSRI and atypcial antidepressants due to their increase safety profile
suppurative conjunctivitis TX
bacitracin- polymyxin B, cirprofloxacin or erythromycin (dont use a penicillin)
Required length of pharm intervention in depression per AHCPR guidelines
6-9m:
-acute phase tx to bring sx under control may last 3m
-cont med for minimum of 6m after depression remission
-relapse highest in first 2 m after discontinuation of therapy
consider maintenance as w/ any chronic illness
Acute recurrent allergic conjunctivits
cromoly opthalmic gtts, oral antihistamies
What are some risks in depression relapse
dysthmia preceding episode (feeling great life is best)
-poor recovery between episodes
-current episodes >2yrs
-onset depression <20yrs or >50yrs
-FHx of depresssion
-severe sx such as suicide or psychosis
Sx of angle-closure glaucoma
sudden HA pain in left eye, blurred vision, pupil dilated, firm eyeball
Seotonin receptor site: 5-HT1C, 5-HT2C: activity when stimulated
influence CSF production, cerebral circulation, regualtion fo sleep. perception of pain, cardio function
comment: reason tachycardia, dizziness, alteration of sleep pattern and change in pain perception occurs w/ SSRI
Sx: vision change w/ dull pain, photophobia, effected pupil is small irregular: What is the ocular disease.
anterior uveitis
Serotonin receptor site: 5-HT1D activity when stimulted (triptans)
antimigraine activity; triptan preparation works by stimulating receptor site, TCA works at this site
what happens if you dont tx primary open angle glaucoma
peripheral vision loss
Serotonin receptor site: 5-Ht2 activty when stimulated
agitation, akathisia, anxiety, panic, insomnia, sexual dysfunction, excessive upregulated in those w/ depression
receptor site highly stimulated in activating SSRI such as fluoxetine. causes sexual dysfunctioni n SSRI,
-nefazodone and trazodone antagonize action at this site and tx of anxious depression and have more favorable sexual profile
Who is at risk of developing primary open angle glaucoma (POAG)
african, DM2 advanced age
Serotonin receptor site: 5-HT3 activity when stimulated
nausea, GI distress, diarrhea, HA
stimulated w/ antidepressant w/ poor GI side effect profile. Zofran blocks activity at site (5-HT3 antagonist)
What is the tx for primary open angle glaucoma?
beta adrenergic antagoinst, alpha agonist, prostaglandin: opthamology referral emergent
Which class has more side-effects: TCA or SSRI
TCA but are superior to SSRI when depresion is moderate to severe also w/ patients w/ pain
Sx: pimple to eyelid, pustule, eye lid margin: what is the dx
hordeolm
Depression w/ episodes of mania is dx w/:
bipolar I disorder
Mania:
-grandiosity or exaggerates self esteem
-reduced need for sleep
-increased talkativeness
-flight of ideas or racing thoughts
-easy distractibility
-psychomotor agitation
-poor judgement
for at least 1 wk
sx: bump on eyelid, hard, nontender swelling lateral border: what is the dx
chalazion
Bipolar 1 disorder is most common in: Men or women
Women: onset around puberty
Tx of hordeolum
oral antimicrobial
Dx of Bipolar 2 is made if
depression has episodes of mania lasting less than 4 days w/ little social incapacitation (remain productive)
Prevention of meniere disease
avoid ototoxic drug (ending in mycin), protect load noise, limit sodium
Cyclothymic disorder includes:
mood disorder present 2yrs w/ episodes of mania lasting less than 4 days
define dizziness
perception of altered equilibrium
If a TCA is given to a person with bipolar disord what do 15% develop?
mania
define vertigo
perception of person or environment moving
define nystagmus
rhythmic oscillation of eyes
What is the onset rate of benzodiazepine:
rapid onset
define tinnits
perception fo abnormal hearing or head noises
Buspiorn (BuSpar) has: high, moderate or low abuse potential?
low abuse potential
Tx of otits external
analgesic (T3), VolSol (acid), steroid w/ an antibiotic like neomycin or florquinolone
New onset of panic disorder findings would include:
peak sx 10min, hx of agoraphobia, chest pain during attack
PE of otits external
tragus pain on palpation, possible conductive hearing loss, drainage
What med is used for panic disorder
Paxil (SSRI antidepressant)
PE of acute otitis media
tympanic membrane immobility
Diagnostic criteria for generalized anxiety include
difficulty concentrating apprehension, irritability
Tx of patient with acute otits media but allergic to PNC
clarithromycin (macrolide)
According to the AHCPR tx guidelines pharm tx for anxiety should be continued for how long
6m AFTER remission is achieved
Tx of otits media not improved after 4 d of amoxicillin would be what antibiotic:
Erythromycin (if PNC allegeric)
Augementin (beta-lactam)
Zithromax (macrolide)
cefuroxime (Second gen cephlasporin)
Which medication may mimic anxiety disorder:
sympathomimetic
M. catarrhalis results from
high beta-lactamase production (PNC worthless)
Rapid w/drawal of lorazapam will result in what side effect
tremors and hallucinations
What is Centor Criteria for pharyngitis
Hx of fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough
Risk of benzodiazepine misuse minimized if a: longer, shorter or rescue (PRN) dose is perscribed
longer duration of action
PTSD may report having:
agoraphobia (panic attack), feeling of detachment, hyperarousal
Define Primary Prevention
measures to prevent onset of targeted condition
Pharm tx for PTSD include
Buspirone (BuSpar): low abuse potential
Example of Primary Prevention
immunization, health education, seat belts...most cost effective form of healthcare
Pharm Tx for irritability and impulsiveness in PTSD
carbamazepine: Tegratol (anticonvulsant)
Define Secondary Prevention
identify and treat asymptomatic person who already have disease but not apparent; alter natural course of disease
OTC herbal used for sx of depression
St. John Wart
Example of Secondary Prevention
screening test; colonoscopy, mammography
Tx resistant panic disorder may respond to
monoamine oxidase inhibitor: caution due to many S/e of medication
Define Tertiary Prevention
Care of established disease to restore highest function while minimize neg effect..primary prevention has been unsuccessful
Define Specificity
proportion of negative which are correctly identified
Tx of pt w/ panic disorder using SSRI w/ the goal being?
reduction in number and severity of panic attacks is the goal
Example of specificity
% of HEALTHY people correctly identified as NOT having a certain condition: Ex: A sore throat that does not have strep has a negative rapid strep, that is specific.
DSM-IV criteria GAD (generalized anxiety disorder)
-excessive anxiety or worry most days for 6m
-difficulty controlling worry, physical or mental distress
-problems cannot be attributed to med or alcohol, disease or other condition
-3 of the following: muscle tension, restlessness, fatigue, difficulty concentrating, irritability, difficulty initiating sleep
Define Sensitivity (statistical)
proportion of actual positives which are correctly identified as having condition (sore throat w/ strep actually has positive rapid strep: that is sensitive)
Depression w/ anxiety reports: which first
nervous feeling after onset of depressed mood
Example of sensitivity (statistical)
% of SICK people who are correctly identified as HAVING the condition
Cardinal presenting signs of anxiety disorder:
tachycardia, hyperventilation, palpitation, tremors, sweating, difficulty falling asleep
define p-value; statistical significance
Represents PROBABILITY of error. Higher P value the less reliable P- 0.5 is borderline acceptable level of error
What mechanism of action do benzo have for anxiety disorders
enhance GABA function and products that enhance availablity of serotonin
define veracity
health professionals honest and full disclosure. Obstain from deceit report lapses in standard of care...ie honesty (medical-dictionary.com)
Which benzo are more lipophilic and why is this important in tx of anxiety
valium or clonazepam: enter brain more rapidly and igniting effect promptly (may feel intoxicating)
note: longer half life left in fat.
Define nonmalficence
avoid harming others (medical-dictionary.com)
Why is it important to know which benzo are more hydrophilic?
slower onset of action less intoxicating same therapeutic effect
Define beneficence
the act of doing good, kindness (medical-dictionary.com)
Which benz may be better for tx anxiety in the elderly
Serax: short half life
Define automony
the act of being independent or self governed
When working to reduce amount of benzo used how much should you decrease it:
25% per wk
Define justice
fairness, up holding what is just
What are sx of w/drawal of benzo w/ rapid removal of med
tremors, hallucination, seizures, delirium tremors
Define fidelity
Faithfulness to obligations, duties, or observances.
What is the average onset age of panic disorders
27 years rare after 45 more common in women if also agoraphobia
Power (analysis) statistics
test ability to reject null hypothesis when actually false. Max is 1 min is 0. should be close to 0 to have high power. determines sample size estimation
What is the tx of choice for panic disorders
SSRI: low side effects better than TCA
Define reliability (truthfulness)
degree consistency which instrument measures variable. Reliable if measurements today are same tomorrow
What is the saying when starting SSRI treatment for panic attach
start low and go slow: Paxil is a good starting w/ low side effect
Define variables (stats)
things measured, controlled or manipulated
What medication is used in PTSD w/ hyperarousal:
clonidine and propanolol: trazadone for sleep
Define correlation as related to research.
Do not influence variables only assess their relation
OTC Herb: St. Johns wort: Are similar to what medications
like MAOI/SSRI, TCA:
less anticholinergic effect, wieght gain than TCA
-similar potential for energizing such as fluoxeting (SSRI)
-TId or QID dosing needed; avoid concurrent use w/ SSRI, TCA or MAO
I
Define experimental research
manipulate some variable then measure the effects: casual relation between variables
What does the BATHE Model stand for (used in emotionally distressed)
B: background
A: affect, anxiety
T:trouble
H: handling
E: empathy
Define dependent ( stats)
only measured or registered NOT manipulated
What are the progestatinal effects when taking oral contraceptives
inhibit ovulation by suppressing lutenizing hormone (LH), thickening endocervical mucus and hampering implantation by endometrial atrophy
Define independent variables (stats)
those that are minipulated
What are the estrogenic effects when taking oral contraceptives
ovulation inhibited by suppression of follicle stimulating hormone (FSH) and LH by alteration of endometrial cellular structure
Define retrospective (historical cohort) and give example
look back at events: ex: review health records to find trends.
How long after discontinuing oral contraception should you wait to conceive.
you do not have to wait
Define prospective (cohort) study
follows group over time of similar individuals who differ on certain factors under study: ex: middle age truck drivers and smoking habits and lung cancer in 20 years
what are non-contraceptive benfits of oral contraceptives
1. lower rates of benign breast tumors and dysmenorrhea,
2. menstral volume reduced 60%,
3. decreased rates of Fe deficiency anemia,
4. decrease endometrail , ovarian, breast cancer if used >5yrs,
6. less PID due to increase endocervical lining,
7. acne, hirsutism, ovarian cyst, PMS, rheumatoid arthritis sx
Internal validity
approximate truth about inferences regarding causes and effect or causal relation
What should you do if you vomit w/in 2hrs of taking oral contraceptive
retake dose
Define external validity
generalizing, the approximate truth of conclusion: degree to which the conclusions in your study would hold for other persons in other places and at other times
If you miss taking an oral contraceptive of 30-35ug, what should you do to ensure continued prevention of pregnancy?
if using 30-35ug
-1 or 2 active pill then: tak as soon as possible and continue taking daily (no additional protection needed.
-Missed >3d ro start a pack 3 day late: take active hormonal pill ASAP an dcontineu pills daily and use condoms or abstain until 7 days of active pills
S. pyogenees pharyngits failure rate w/ tx with IM PNC
20% similar to oral tx
If missed oral contraceptiv of 20ug or less ethinyl estrodiol
missed 1 active pill then:
take active pill ASAP and continue pills daily (no other protection)
Missed >2d or start 2d late then: take hormonal pill ASAP use condom for 7 d
Expect onset when using nasal corticosteroid spray
a few weeks
A women with seizures would do better on what type of contraception
depo-provera: due to progestin protection against seizures.
What is a drug of choice for allergic rhinits
claritin
What class of contraception have potassium sparing qualities
drospirenone in yasmin (progestin) use w/ caution in hepatic or renal dysfunction
What receptors do antihistamines effect
H1 receptors
What additional medication can reduce breakthrough bleeding when using depo
ibuprofen, naproxen BID for 3-5 days
What are the action of decongestants
vasoconstriction
what supplement should be encouraged when taking depo:
calcium at 1000-1500mg/day
What medication is used for relief of acute nasal puritis
oral antihistamine
What is the soonest that a diaphragm may be removed after sex
6hrs should use a spermacide with the diaphragm
ARIA (Acute Rhinitis and Impact on Asthma) guidelines : best relief of acute nasal congestion
decongestant spray
A woman w/ recurrent UTI would or would not be a good candidate for a diaphrahm:
would not due to the need for spermacide
ARIA: least control of rhinorrhea
Cromoyln nasal spray
WHO precaution for OC
DVT, CHD, CVA, heart disease, breast cancer, prego, laction <6wk pp, hepatitis, HA w/ neuro sx, >35, smoker>20cig day known thromboic mutation factor V Leiden
What are the pathophysiological effects of Cromolyn (tx for asthma)
mast cell stabilizer
What percentage of women experience hot flashes during menopause
80% have hot flashes and night sweat
What are the effects of leukotriene modifiers (Singular)
inflammatory inhibitor (allergy medication used to decrease airway inflammation and mucus production)
Estrogen deficient vaginitis: what lab finding would u find
vaginal pH >5
GLORIA (global resource in allergy): Tx of allergic conjunctivitis
topical mast cell stabilizer (Cromolyn) w/ topical antihistamine
53y/o on hormone therapy w/ conjugated euqine estrogen having vaginitis sx should also take what topical and where
topical estrogen to the vagina
One common method to control allergies especially at night
dust mite control
relative contraindication to postmenopausal HT include:
seizure disorder, dyslipidemia, migraine headache
Acute bacterial rhinosinusitis Dx
URI >7-10 or worsening in 5-7 days
Absolute contraindication to postmenopausal HT
endometrial cancer
What sx do you find on acute bacterial rhinosinusitis (ABRS)
maxillary tooth ache, colored nasal discharge, URI
When advising perimenopausal women about HT you consider a benefit to include:
HT helps preserve bone density and reduce risk of osteoporosis
first line tx of acute bacterial rhinosinusitis
amoxicillin
post menopausal HT effects on bones include:
reduction in frequency of spinal and hip fx
Failure of treatment of acute bacterial rhinosinusitis after 72 hrs progress to:
augmentin
Progestin component of HT is given to:
minimize endometrial hyperplasia
What is the next Tx of acute bacterial rhiniosinusitis if already tx with doxycycline and a (PNC allergy)
levofloxacin (quinolone)
Selective estrogen receptor modulator therapy (Evista) helps:
in the reduction of osteoporosis and breast cancer risk
acute bacterial rhinosinusits that appears moderaly ills
tx with high dose augmentin
during perimenopause sx will most likely:
be in the week before the onse to menses
blephritis: sx; tx
ocular burning, eye lid margins red w/ scaling or crusting: + pain
warm compress, daily lid scrub, erythromycin or bacitracin ophthalmic
What is noted in short=term <1-2yrs HRT use in post menoausal
HRT can minimize menopausal sx
cellulits orbital Sx and Treatment
localized tenderness, erythema, edema, fever, proptosis; + pain
referral, IV antibiotics
What body area has highest estrogen receptor sights
vulva
dacryosystitis
chronic tearing, eyelash crusting, tenderness, circumscribed erytheema; + pain
warm compress, gentle massage, systemic antibiotics
What sx are tx when using black cohosh use in menopause?
decreased frequency and severity of hot flashes
What are the sx of chalazion
nontender chronic lesions, locaized erythema, edema of eyeids no pain
warm compress, daily lid scrubs, lid massage
Adding androgen to HT may well be suited for woman w/
sever hot flashes in spite of maximized estrogen therapy
hordeolum
tenderness, erythema, edema, internal lesion; +pain
warm compress, lid scrub for recurrence, topical antibiotic
typical HT regimen containts---of estrogen dose of oral contracetpive
1/4th
angle-closure glaucoma, sx, tx
sever pain, n/v, halos around lights, photophobia, cornea cloudy w/ decrease vision, conjuctival.
emergent refereal to opthomologist, pilocarpine
Black cohosh during perimenopause will likely do what physiologically:
bind to estrogen receptors decreasing side effects of premenopause
conjunctivits allergic, sx tx
pruritus, conjnctival hyperemia, chemosis, watery or stringiy discharge; no pain
avoid allergens, cold compresses, topical and systemtic medications
Why do menopausal women get hot flashes
Lutinizing Hormone surge/flucuations in estrogen in 80% of women. surgical menopausal women have more sever sx
conjunctivitis bacterial, sx tx
photophobial w/ blepharospasm, mucopurulent discharge w/ eyelash matting edema, hyperemia, preauricular adenopathy only w/ hyperacute disorder: may or may not have pain: topical antibiotic gtts, systemic antibiotics if gonococcal or chlamydial
What deficiency during menopause increase risk of osteoporosis
estrogen
conjunctivitis viral sx,tx
acute onset w/ systemic illness, photophobia or foreign body sensation, preauricular adenopathy, hyperemia, chemosis, water discharge classic dendritic corneal lesion w/ herpes:
Tx; supportive tx, cool compress, topical artifical tear, referral if herpatic
Why do you use progestin during HT versus just estorgen:
endometrial cancer risk and breast cancer (contraindicated in hx of breast cancer)
Which of the following are absolute contraindication to postmenopausal estrogen therapy?
a. unexplained vag bleed
b. breast cancer
c. acute liver disease
d. all of the above
-unexplained vag bleed
-acute liver disease
-thrombotic disease
-endometrial cancer
-neuro-opthalmologic vascular
-breast cancer
What are sx associated w/ corneal foreign body, abrasion, or an ocular ulcer
intense pain, photophobia, conjunctival hyperemia, decrease acuity, ulcers, prior hx f trauma w/ abrasion but not erosion
topical antibiotics systemic pain relief for abrasion and after foreign body
What are relative contraindication to postmenopausal estrogen therapy
seizure disorder, dyslipidemia, migraine, thromobophlebitis, gallbladder disease. absolute: vag bleed, coagulation disorder until corrected
What are sx of episcleritis or scleritis and how do you manage them.
mild to sever pain, circumscribed erythema of affected sclera, vision unaffected
episcleritis self limiting, scleritis referral
Tamoxifin is a SERM that locks out estrogen effects on what body part
breast
What are sx of iritis or uveitis?
pain, photophobia, conjunctival hyperemia, pupil constriction, no discharge: urgent referral
urge incontinence define and intervention
involuntary loss of urine: behavioral, voiding schedule
What are sx of keratitis
pain photophobia corneal cloudiness w/ stromal involvement
urgent referral
What medication is used for urge incontinence
terodiline (selective muscarinic receptor antagonist) relaxes smooth muscle and bladder pressure
Disease that cause sudden eye sight loss
acute angle-closure glaucoma, central retinal vessel occulsion , hyphema, irtitis, meningitis, migraine, optic neuritis
urge incontinence: most common in elderly: what is the Sx, Tx
sensation need to empty bladder cant be controlled, involuntary loss
Tx: avoid stimulants, gental bladder stretch by delay void, reduce bladder contration w/ detrol or ditropan
disease cause gradual loss
cataracts, corneal opacities, glaucoma, macular degeneration, pituitary tumore, retinal detachement
What Sx, Tx of stress incontinence:
path: weak pelvic floor and urethral muscle.
Found in women rare in men:
Sx: sneeze, exercise, cough results in urine loss.
Tx: kegel, support w/ vag tampon, urethral stent, pessary use. Topical estorgen, phenylpropanolamin (alpha agonist)
Cataracts; SX, Tx
blurry vision, film, dull red reflex, opaque pupil, Tx: glasses, light, stop night driving, surgical when need exceeds vision
Peds: tx immediate risk of amblyopia
Urethral obstruciton: of outflow (prostatic, stricture, tumor. Older men: sx tx
dribbling post-void and urge incontinence on presentation
Tx: treat urethral obstruction
What is the tx for chalazion, hordeolum, blepharitis
Tx: Warm compresses, bacitracin, erythromycin or Cipro if chronic
hordeolum: children
chalazion: adults
transient incontinence results from what underlying process:
delirium, UTI, medication, restricted activity (bed ridden). tx underlying process, discontinue offending medication
cardiac: AAA: what increase risk of rupture
>6.0 cm, rapid expansion, female, smoking, COPD, FHx, asymmetrical AAA
What is common in women during reproductive years:
vag pH of 4.5 or less
-lactobacillus predominant vag organism
-thick, white vag secretion during luteal phase
AAA: PE
75% asymptomatic..pulsating mass (knees flexed), back pain
What does vag discharge appear during ovulation?
stingy and clear
AAA: Dignostic
Abd US (screenin an dconfirmation
Vaginal itch w/ perineal excoriation, erythema, white, clumping discharge: microscope would reveal
hyphae (yeast in budding form)
AAA: TX
prevent rupture: size best predictor
Bacterial vag presents w/
malodorous discharge
AAA: refer
>4.0 cm to vascular surgon
tx of vulvovaginitis by Candida albicans:
clotrimazole cream (lotrimin) antifungal : tx thrush, ringworm, athletes foot
A-fib: PE
palpitation (shorten diastole and vent filling), drop in BP, CO, light headed, dizziness, fatigue, SOB
1wk thin, green-yellow vag discharge w/ perivag irritation; vag eryth, petechial hem on cervix, WBC, motile organ what is the dx
trichomoniasis
A-fib: PE sx
if hyptensive and tachy immediate care
Tx of trichomoniasis
metronidazole (flagyl) antibiotic: Tx also C. diff, H. pylori other parasitic infection
A-fib Heart sounds
possible systolic ejection murmur, if S3 then impending heart failure
Tx for bacterial vaginosis:
oral metronidazole (flagyl), clindamycin cream, oral clindamycin (Cleocin)
A-fib: diagnostic
ECG, holter (24-48hr), provocative test (exercise ECG), ECHO for initial work up on all arrhythmias to determine left atrial and ventricular size
w/o sx but partner has dysuria w/o discharge, she has friable cervix covered in thick yellow discharge what is the infection
chlamydia trachomoatis
what is the heart rate of PSVT
140-240bpm
Tx for N. gonorrhoeae
Ceftriaxone (Rocephin), or cefixime (suprax): used also in ear and throat infections
Torsades de Pointes
QRS morpholgical pattern, TX: magnesium
Gonococal infections are symptomatic in most males: true or false
false: most are asymptomatic
A-fib tx:
tx causes: rheumatic heart, mitral valve, HTN, CHD, hyperthyroid, acute alcohol, stimulant ect
Complications of Gonococcal and chlamydial GU infection in women include:
PID, tubal scarring, peritonitis
A-fib tx:
uninterrupted anticoagulants for 4 wks prior and post conversion
Initial complaints in women w/ HPV-2
painful ulcer, inguinal lymphadenopathy, thin vaginal discharge
A-fib tx:
anticoagulant: warfarin: INR between 2-3 if contraindicated then ASA and if <60y/o
Tx for HHV-2 genital infection
famciclovir: also used to tx herpes zoster (shingles)
first degree AV block
PR>20
What would you prescribe for chlamydia infection
doxycycline, erythtromycin, azithromycin (best) efficacy
Second degree type I: mobitz type 1
pregressive prolongation of PR interval until not conducted by ventricle
What is the incubation of Gonnorrhea: how do women infected present
1-5days: dysuria, milky purulent blood tinged discharge
What do you expect to see on the ECG w/ Second degree type II: mobitz II
constant PRI interval (normal) until P wave is not conducted: more severe vs type I. Fails to conduct through the ventricles.
Lymphogranuloma venerum: clinical presentation and tx
vesicular or ulcerative leasion on external genitalia w/ inguinal lymphadenitis or buboes
Tx: doxycycline 100mg BID x 21d or E-mycin 500mg QID x 21d
Third degree AV block
no relaiton between P and QRS, fatal
nongonococcal urethritis and cervicitis (not pregnant): PE and Tx
-PE: cervicitis, irritative void sx, mucopurulent discharge
-Tx: Azithromycin 1 g PO single dose or doxy 100mg BID x7d
alt: E-mycin 500mg QIDx7d or levofloxacin 500mg QD x7d
What is included in a diagnostic work-up for A-fib?
ECG, holter (24-48hr), provocative test (exercise ECG), ECHO for initial work up on all arrhythmias to determine left atrial and ventricular size
Gonococcal urethritis (not pregnant): PE and Tx
irritative void sx, purulent discharge
single dose for uncomplicated:
-cefixime 400mg po, cetriaxone 125mg IM or cipro
concurrently tx w/ Azithro 1g x1, doxy 100mg bid if chlamydial infection not ruled out. may consider spectinomycin
PSVT: rate
140-240bpm
Pelvic inflammatory disease: PE and Tx
irritative void, fever, Cervical motion tenderness
TX: a: ofloxacin 400mg bid or levo 500mg QD w/ or w/o metronidazole 500mg BID x 14d
B: ceftriaxone 250mg IM plus doxy100mg BID x 14d w/ or w/o metronidazole 500mg bid x 14
Describe the wave pattern of Torsades de Pointes and the tx?
QRS morpholgical pattern, TX: magnesium
trichomoniasis: PE and Tx
dysuria, itching, vulvovaginal irritation, dyspareunia, yellow-greeen vag discharge, cervical petechial hemorrhage (strawberry spots), motile organism and WBC on microscope
TX: metronidazole 2 g x1, metronidazole 500mg BID x 7 d
A-fib tx:
tx causes: rheumatic heart, mitral valve, HTN, CHD, hyperthyroid, acute alcohol, stimulant ect
Bacterial vaginosis PE and Tx
clue cells, pos whiff test,increase volume discharge: thin, gray, buring, pruritis: pH >4.5, few WBC
-CDC: metronidazole (flagyl) 500mg Bid x 7d, 1 applicator 5g intravaginally QD x 5d or clindamycin cream 2%, 1 applicator intravag at HS x 7d
A-fib tx:
uninterrupted anticoagulants for 4 wks prior and post conversin
candidiasis: PE and tx
PE: itching, burning, thick white to yellow discharge, vulvovaginal excoriation, erythema: HYphae, pH<5
Tx: miconazole (antifungal), fluconazole, terconazole
A-fib tx:
anticoagulant: warfarin: INR between 2-3 if contraindicated then ASA and if <60y/o
chancroid: PE and tx
painless genital ulcer
Azithro (macrolide) 1g oral x1 or ceftriaxone (cephlasporin/Rocephin) 250mg IM x1, or cipro 500 BIDx3d or Emycin (Macrolide) 500tidx7d
What finding on an ECG would help dx first degree AV block?
PR>20
Genital Herpes: PE and tx
PE: painful ulcerated lesion, lymphadenopathy, thin vag discharge if lesion near vagina or introitus.
- Tx: inital: acyclovir 400tidx7-10d or famciclovir 250tidx7-10d or valacyclovir 1g bidx7-10d
Second degree type I: mobitz type 1
pregressive prolongation of PR interval until not conducted by ventricle
genital warts (condyloma acuminata): PE and tx
verruca-form lesions or may subclincial unrecognized
tx: podofilox 0.5% solution or imiquimod 5%:
cryotherapy, tricholroacetic acid, surgical
Second degree type II: mobitz II
constant PRI nterval until P wave is not conducted: more severe vs type I
Pelvic inflammaotry disease presents w/
dysuria, cervical motion tenderness, diffuse abd pain abnormal vag bleed, GI, fever
what do you expect to see on the ECG w/ Third degree AV block
no relation between P and QRS, fatal
Blood pressure norms
<140/90; <130/80 if heart failure or renal
Most common pathogen in pelvic inflammatory disease
c. trachomatits
lipid norms
LDL <100; reduced saturated fats < 7% calories
Triglycerides <150 mg
Tx for Pelvic inflammatory allergic to PNC:
ofloxacin w/ metronidazole
How much physical activity is suggested
30 min, 7 days week
What labs should be obtained w/ Pelvic inflammatory
elevated ESR or C-reactive protein, leukocytosis w/ neutrophilia
weight norms
BMI: 18.5-24.9; waist M <40 W<35
Tx of pelvic inflammatory may include
ceftriaxone 250mg IM x 1, followed by doxy 100bidx2wks
What lab finding is diagnostic for diabetes mellitus
A1C: >6.5%
sequelae to genital condyloma may include
cervical carcinoma
meds used for CAD; ASA if
75-162mg PO QD; if contra then clopidogrel or warfarin. May be combined
Describe condyloma lesions
verruciform: Shaped like a wart or warts
Meds used for CAD: Beta blocker if:
If MI, ACS, left ventricular w/ or w/o HF
meds for CAD: ACE-I if:
Ventricular ejection fraction <40% and w/ HTN, DM or CKD
meds for CAD: Influenza vaccine
all CAD
variant angian patho
spasm most right coronary and left descending: focal and reproducible at same location
% of anogenital and cervical cancer caused by HPV
95%
Mechanism of action of imiquimod (aldara)
immune modulator condyloma acuminatum
PMI define
point of maximum impulse
HPV type cause condyloma
HSV 6 and 11
Where do you expect to find PMI w/ cardiomegaly
downward or laterally displaced
HPV most often in cervical cancer
HPV 16 and 18
what is present w/ primary syphilis
painless ulcer, palpable inguinal nodes, spontaneously healing lesion
define xanthomas or early arcus senilis
elevated cholesterol seen around iris as hazy whiteness: assess peripheral circulation
% of anogenital and cervical cancer caused by HPV
95%
What is present in secondary syphilis
generalized rash, arthraligia, lymphadenopathy
Ventricular gallop (S3) indicates possible
heart failure
What is imiquimod (aldara) used for?
a. actinic keratosis
b. superficial basal cell carcinoma
c. genital and anal warts
d. all of the above
D. actinic keratosis, basal cell carcinoma, genital warts:
It is an immune response modifier
What is present in tertiary syphilis
Gumma (lesions found on liver, heart, brain, skin)
atrial gallop (S4) indicated possible
HTN, MI , resistance of ventricular filling
HPV type cause condyloma
HSV 6 and 11
Sx usually present after how many weeks upon contact w/ syphilis
2-4 wks after contact
what is first line tx of syphilis
penicillin
systolic mitral regurgitation murmur indicates
ischemic papillary muscle
HPV most often in cervical cancer
HPV 16 and 18
what is present w/ primary syphilis
painless ulcer, palpable inguinal nodes, spontaneously healing lesion
What is the pathophysiology of pericardial friction rub:
inflammation around pericardial sac
% of anogenital and cervical cancer caused by HPV
95%
What is present in secondary syphilis
generalized rash, arthraligia, lymphadenopathy
Name on diagnostic test for coronary artery disease (CAD)
exercise tolerance test (stress test)
Mechanism of action of imiquimod (aldara)
immune modulator condyloma acuminatum
What is present in tertiary syphilis
Gumma (lesions found on liver, heart, brain, skin)
In coronary artery disease w/ previous myocardial injury what changes to the ST segment on the ECG do you expect to find?
a. ST depression
b. ST elevation
depression >1mm high likelihood of unstable angina
Sx usually present after how many weeks upon contact w/ syphilis
2-4 wks after contact
Cardiac markers: CPK-MB norms
rises 3-12, peak: 24hr, normal 48hr after injury
what is present w/ primary syphilis
painless ulcer, palpable inguinal nodes, spontaneously healing lesion
What is present in tertiary syphilis
Gumma (lesions found on liver, heart, brain, skin)
Endocarditis: causes
streptococcal (70% if not IV drug use),
what is first line tx of syphilis
penicillin
What is the name of a fertilized ovum?
Zygote
What is the "baby" called up to 2 weeks postconception?
blastocyst: stage prior to embryo forming, lots of cell division
Endocarditis: diagnosis
consider for all patients w/ murmur and fever of unknown origin
Stage: 8-12wks post conception is called
Embryo
A nongravida uterus would be the size of a
large lemon
An 8 weeks uterus woudl be the size of a
tennis ball/ orange
Cardiac markers: myoglobin norms
rises 1-3 hrs, peak 3-4 hrs, normal 24 hrs after injury
At 10 wks uterus would be the size of a
baseball
Peripheral venous insufficiency: DVT: causes
prolonged inactivity, estrogen, recent surgery, trauma
cardiac markers: troponin, norms
rises 3-12 hr, peak 3-4 hr, 14d
At 16wks the fundus of the uterus would be in what location
halfway between the symphysis pubis and umbilicus
What causes Endocartitis?
streptococcal (70% if not IV drug use),
At 20 wks the fundus should be at what land mark
the umbilicus
Endocarditis: sx
fever main sx (unless old, immuno), heart murmur, janeways lesion, osler nodes: palms of hands, soles due to septic embolization
What % of babies are in the vertex position by 36th wk of preg
95%
Endocarditis: tx:
high dose bactericidal IV: PNC G r ceftriaxone and an aminoglycoside
What is recommended weight gain durign pregnancy w/ normal BMI
25-35lbs
When would endocarditis be part of your differential diagnosis?
Consider for all patients w/ murmur and fever of unknown origin
Normal BMI: what is the average daily intake ontop of normal calories during pregnancy
300 kcal
Heart Failure: Sx
S3 or s4 murmurs and lateral displacement of apical impulses, S4 due to over distention of ventricles
Normal BMI: waht is daily calorie requirement on top of normal diet when lactating:
500 kcal
Heart Failure: Diagnostic: lab
BNP: brain natriuretic peptide: secreted due to elevation of end diastocli pressure: BNP >400= CHF Dx
Waht is the recommended Ca intake during pregnancy
1200-1500
Heart failure: Diagnostic: rad
Echocardiogram
Maternal Fe is greatest in what part of pregnancy
second and third trimester
What are causes of Peripheral venous insufficiency: DVT
prolonged inactivy, estrogen, recent surgery, trauma
What is the most common acquired anemia during pregnancy:
iron deficiency
DVT sx:
leg edema, calf tenderness, pain on dorsiflexion of foot (Homans sign), 50% no sx
Give an example of neural tube defect:
anencephaly, spina bifida, encephalocele
DVT diagnostic: Rad: none unless superficial phlebitis
duplex ultrasound to ensure no DVT
What is the leading causes of preventable fetal mental retardation
fetal alcohol syndrome
DVT diagnostic: Lab
D-Dimer: marker for coagulation activiation and fibrinolysis
risk associated with Pica intake:
constipation, bowel obstruction, nutritional deficiency
DVT: common location
femoral veins
How much does blood volume increase at 42 wks. 25%, 50%, 75%
50%
DVT: Tx
superfical phlebitis: elevation of leg, compression w/ ace bandage, NSAIDS, antibiotics
Drop in diastolic BP is most notable in what trimester
second
DVT: Tx
heparin immediatley to prevent PE, hospitalization: 500u boluse then 800-1400u/hr--> PTT >2x normal for 2 days
S1 heart sound become louder or quieter during pregnancy
Louder
DVT: Tx
coumadin w/in 24 hrs, pt discharged when INR 2-3 and continued for 3-6m
What type of murmur becomes evident during pregnancy
physiologic systolic ejection
Foods that decrease effectiveness of warfarin:
high in vitamin K
What happens to the renal collecting system during pregancy:
it dialates
Chronic venous stasis: TX
compression stocking, normal saline wet to dry topical antibiotics for ulcers
Is it common to find physiologic glucosuria and proteinuria during pregnancy
Yess: it is common to find glucosuria and proteinuria
chronic venous stasis: Tx
stocking if eczema from sever stasis the 0.5% hydrocortisone
What happens to the transvers thoracid diameter and diaphragmatic contraction
it increases in size
Varicose: causes
pooling blood in large varicose veins
What happens to the lower esophageal sphincter during pregnancy
the lower sphinchter relaxes
varicose: sx
heavy discomfort when standing increase bleed when older
What happens to the intestines regarding motility during pregnancy
the intestine slows down
Varicose: Tx
asymptomatic, refer if poorly tolerated
What happens to the gallbladder during pregancy
the gallbladder doubles in size
Venous stasis ulcer sx include:
most sever complication of post phlebitic syndrome: ulcer above medial malleousl, wound infected, pulses not palpable due to swelling
What happens to insulin levels during pregnancy
they increase 2-10 fold
venous stasis ulcer tx;
bed res, wet-dry, ulcer debridment, oral antibiotics, compression w/ ACE
What happens to fasting plasma glucose during pregnancy
It should remain the same, test for gestational diabetes
Venous stasis: things to know
occur around ankle, hx of phlebitis, sx of venous stasis, painful when infection, improved w/ elevation
What is Hegars Sign in pregnancy
uterine isthmus become soft and compressible
venous ischemia: things to know
occur at tips of extremities/heel, Hx of cluadicating, very painful WORSE with elevation, absent pulse, secondary infection spread quick
What is Chadwicks sign
Cervix color and texture change becoming cyanotic
Where and when do you expect to find venous neuropathic (diabetic)
occur at pressure points, painless but co-exist neuro pain, present after infection
What is Goodwells sign
Cervix becomes less firm
Murmurs: things to know
timing is most improtant, mitral regurg best heard apex or 5th intercoostal, S1 loudest at apex and lower left sternal border
What happens to the breast during pregnancy
nipples, areolae darken and increase in size. Venous congestion
Murmurs: things to know about S4 and atrial kick
S4: atrial kick into noncompliant ventricle
What happens to breast tissue during pregnancy
increase nodules due to proliferation of lactiferous glands
Aortic stenosis: location, PE, Tx
right sternal border, CP< syncope, dyspnea, surgical
What happens to the blood during pregnancy
volume increases by 40-50% peak at 32 wks, RBC production increase by 33%
mitral regurgitation: locatin, PE, tx
apex, asymptomatic, then fatigue, dyspnea on exertion. if acute: Iv antibiotic, preventative for dental or surgical
Why does dilutional physiologic anemia occur during pregnancy
the RBC increase by 33%
Mitral valve prolapse: where can you hear it, what are the sx and what is the tx?
lower left sternal, PE: asymptomatic, then CP, palpiation,dyspnea, fatigue. Tx: none except echo q 3-5yr; antibiotic for dental
What happens to the renal system during pregnancy
increased blood flow and GFR, dilation of renal collecting
Where do you listen to hear tricuspid regurg
lower left sternal listening point
Also: ventricular septal defect
Why does the physiologic glucosuria and proteinuria occur during pregnancy
The GFR increases so renal cant reabsorb glucose and protein
aortic regurg
lower left sternal, asymptomatic, then acute CHF, Tx; antibiotic prevent endocarditis, valve replace
What happens to tidal volume and residual volume late in pregnancy
Tidal volume increases and residual volume is reduced
mitral stenosis
apex left lateral, class 1: asymptomatic, Class 2: dyspnea w/ exertion. Tx: if A-fib then w/ anticoagulants
What happens to the digestive system during pregnancy
lower esophageal sphincter relaxes due to pressure, intestine and stomach slow to allow absorption on nutrients
HTN: BP ok
<120-90
What happens to the gallbaldder during pregnancy
it doubles in siz, dilute bile and increase risk of stones
Prehypertension
120-139/80-89
What account for weight gain in a health pregnancy
first half: maternal weight change
Second half: components of pregnancy
Stage 1 HTN
140-159/90-99
When should the triple screen be done: wks
16-20 wks
What are the parameters for Stage 2 HTN
>160/>100
How often are visits during 28-32 wks
every 2 wks
Primary HTN: Patho
renin-angiotension: inappropriate feed back loop--> constant vasoconstriction
List the appropriate weight gain during pregnancy at
<19wks, 19-26, 26-29, >29wks
a. 28-40lbs
b. 25-36lb
c. 15-25lb
d:15+lbs
Primary HTN: Patho: vascular
hypertrophy<-- excess insulin, catecholmines, natriuretic hormone-->increase peripheral resistance
What prenatal care: first visit:
pap smear, rubella titer, PPD, VDRL, RPR, HIV, Blood type, antibody screen, GC/chlamydia, Hg electrophoresis (african, asian), UA urin C&s
Primary HTN: path: obesity
central-->increased sympathetic nervous system output
Fetal loss occurs in 1 in ____ amniocentesis
1:200 deaths
HTN: diet
DASH: fruits, veg, low-fat dairy, Sodium: increase circulatory volume
What may be causes of an elevated Alpha-fetoprotein (AFP)?
underestimated gestational age, open neural tube defect, meningomyelocele
HTN prevention: How does alcohol increase BP?
increase BP due to SNS, RAS decrease peripheral vascular tone
What are some pregnancy test from 16-20 wks
24-28wks
28-32 wks
16-20: triple marker/screen US
24-28: 1-hr glucose load; if Rh neg, T&Screen
28-32: Hg, STI testing as indicated (HIV, HBsAg, GC, chamydia) RhoGram
Renal artery stenosos HTN: PE, screen
<30->50, Hx arterhosclerosis, Screen: UA, creatinine
What are the pregnancy care test: 32-36wks, 35-37 wks, 40-42wks, 41+wks
32-36 fetal presntation, kick count (fetal movements ?4 in 1 hr;>10 in 2 hr)
35-37: grp B stretpococcus culture (rectal and vag)
40-42: vag exam to assess cervical ripness, fetal station
41+ Nonstress test, biophysical profile
HTN: pheochromocytoma: PE Screen
5 H: HTN< HA, hyperhidrosis, hypermetabolic, DM
Screen: spot UA, 24hr UA
Edwards syndrome is from trisomy:
18
renal artery stenosis HTN: Diagnostic, TX
ateriogram: Tx: B-blocker, AVOID ACE-I, angioplasty, bypass
Edward syndrome most kids live a full life: true or false
false: most affected infants die during first year of life
HTN: pheochromocytoma: diagnostic, TX
CT abdomen, Tx; A-blocker, then B-blocker, or both
what is a major risk factor for being born w/ down's syndrome
born to women older than 35yrs
Hyperaldosteroinism: PE, Screen
weakness, HA, fatigue, HTN, hypokalemai: Screen: unprovoked hypokalemia
Downs syndrome is from trisomy
21
thyroid HTN: , Screen
wekness, HA, fatigue, HTN, hypokalemia, Screen: aldosterone levels w/ saline challenge
What are the components of the triple screen test in pregnancy
AFP, hCG, unconjugated estriol
Thyroid HTN: Diagnostic,
Tx
thyroid binding, Tx: disorder, control HTN
What are two test to assess for congenital defects in utero
amniocentesis or chorionic vilus sampling
Renal parenchmal disease: polycystic kidney: PE, screen, diagnostic, Tx
edema, nocturis, diabetes, Screen: 24hr UA, protein, creatinine renal US, DM test control volume, diurectis, ACE-I if diabetic
What are the physical findings of edward syndrome
low birth weight, mental retartation, cranial, cardiac renal malformation
Cushing Syndrome HTN: PE, screen, diagnostic, Tx
hirsutism, edema, buffalo hump, moon face, truncla obesity, screen: 24 hr UA free cortisol, Diag: dexamethasone, suppression test, pituitary MRI, Tx; surgery
What are examples of neural tube defects:
meningomyelocele, anencephaly, spina bifida
JNC7 f/u for initial BP w/o end organ if : normal <120/<80
f/u in 2 yrs
Where is alph-fetoprotein synthesized in fetus
yolk sac, GI tract, liver
JNC7 f/u for initial BP: preHTN
1yr
What can lead to misinterpreted AFP test: it can be higher in earlier pregnancy
underestimate gestational age
JNC7 f/u for initial BP: stage 1 HTN
confirm in 2 months
What is the most sensitive marker for detecting trisomy 21
increase hCG level: Low hCG indicates trisomy 18
JNC7 f/u for inistial BP: stage 2 HTN
eval or refer for care w/in 1 m
Triple screen is not diagnostic they are used in pregnacy to...
assess for risk of nural tube defect
HTN PE:
papilledema, buits, neuro deficit, skin thinning, loss of extremity hair, striae
Medication most commonly pass through placenta via:
passive diffusion
What diagnostic test should u obtain for a new HTN patient?
UA, CBC, glucose, CMP, BUN< creatinine, uric acid, TSH, 24-hr urine cortisol if cushing syndrome suspect
Osteoarthritis Sx
pain, stiffness and limited ROM, metacarpal joints of thumbs and interphalangeal joints initial impact
What is the category for safe for use in pregnancy:
cat: a
Osteoarthritis: Tx
APa primary 1 g 4x dayily, Tramadol nonopiod pain may be used w/ NSAID, glucosamine w/ or w/o chondroitin for OA of knees
Med that cause teratogenic in humans but benefit outweights risk of use in life threat assigned cat
cat: D
Osteoarthritis: non-pharm Tx
aerobic for cardio, weight reduction, PT and or OT, strength training to fix contractures
Which of medication is pregnacy risk D: Misoprostol, Captopril, Cefuroxime, regular insulin
Captopril (ACE-I) HTN HF med (capoten)
Osteoarthritis: Diagnostic
xray films normal early; later narrowed asymmetric joint space
none systemic disease so no serologic markers, labs to rule out other diseases
Drugs cause teratogenic in animals but not in human assign preg risk:
Cat: C
Osteoarthritis: Injections limits
3 injections per year and max of 12 per joint (may accelerate joint deterioration)
Preg at 38wks w/ UTI may tx w/
Amoxicillin w/ clavulanate
What are the Sx of Acute Gout/Hyperuricemia
rapid onset, at night wakes from sleep, warmth, red, swell, decrease ROM, monoarticular, First metatarsophalangeal big toe (podagra)
Preg w/ asthma; when may bronchospasm worsen?
29-36wks
What are sx of chronic Gout (tophaceous)
typically>10yrs firm swelling, digits of hands and feet
Preg w/ acute bacterial rhinosinusistis may tx w/
amoxicillin, cefuroxime, azithromycine but NOT levofloxacin
What increase risk of Gout flare up?
trauma, overeating, alcohol, fasting.
according to IDSA duration for antibiotics for tx of UTI during preg is:
7 days
What is the non-pharm prevention and tx of Gout flare up
diet is key: avoid diuretics weight gain, alcohol (lowers purine, protein), TX: cold compress
SSRI w/ drawal syndreom best characterized as
bothersome but not life threatening
How do you dx Gout
joint aspiration: 6-13 minor or 1 major crystals in synovial fluid or tophus for Dx
The placenta is best able to transport what type of substance
Lipophilic
What is the pharm Tx of ACUTE Gout
NSAID: (unless risk: >65yrs, creatinine <50ml/min, CHF, peptic ulcer, anticoagulant, hepatitis) High dose in first 24-48hrs.
-If ONLY 1-2 joints consider intra-articular injection
-if multiple joints or NSAIDS not tolerated use corticosteroid taper dose 7-14d
-colchicine 1mg then 0.5 q2h until absent sx or GI problems: only effective in first 12-24hrs..contra if GFR>10
2nd trimester w/ migraine Ha best tx would be
Ibuprofen
What is the pharm Tx of Chronic Gout
Maintain serum Urate <6 (below normal), DO NOT start urate lowering during acute attack start 6-8wks after: (lengths attack)
-NSAIDS
-allopurinal 100mg until SU<6
Colchinicine 0.5-1mg to prevent rebound gout
-Febuxostat: 40mg/d
-probenecid (if contra allopurinal)
SSRI during preg: study has shown the affects on infants later in life
had no observable difference
Tennis Elbow Sx
Medial epicondylitis (GOLFERS) pronators
Lateral epicondylitis (TENNIS) supinators
-Tinel's sign: tapping over ulnar groove reproduces pain/numb to 4-5th fingers
SSRI w/ longest half-life:
Fluoxetine (Prozac)
What is the prevention of Tennis elbow
overuse, proper techinques, lighter tools, less grip
Most commonly used medication during 1st trimester in pregnancy
antibiotics
What is the diagnostic of Tennis elbow
xray, AP, joint aspiration for crystals
Benzodiazipine w/ drawal risk includes
Seizures
What is the managment of Tennis elbow
NSAID, RICE 2 wks; consider steroid injections.
Tx of chronic asthma in patients that are preg is:
short-acting beta agonist
Other elbow injuries: things to know
Radial head fx: RICE, posterior splint elbow flexed at 90
-Ulnar neurtitis: rest affected hand, elbow pads, wrist-elbow splint, neutral position
-Olecranon bursisits: ray, aspirate bursa for dx, hosp if septic
24wks preg w/ acute asthma flare should be given:
montelukast (singulair): a leukotriene receptor antagonist (LTRA)
What are the modifiable risk factors of Osteoporosis
low body weight <58kg,BMI<20, Ca or Vit D, inadequate physical activity, smoking, alcohol, corticosteroid, heparin
Drug know to be harmful to fetus given cat
X
What are the non-modifiable risk factors of Osteoporosis
advaced age >65, female, caucasion, asian, FHx, traumatic fx
Sertraline is preg risk cat;
cat: D (pos evidence of fetal risk) may is specific cases still be used. Doxy, ARB, ACE-I
Osteoporosis prevention
Ca 1200mg and vit D 700 IU/d. Screen all women >65 or 60 w/ risk factors
Clonazepam in preg is cat: B,C,D,X
cat: D (pos evidence of fetal risk)
Osteoporosis diagnostic test
Dexa of lumbar and Hip is GOLD standard for dx, T-score >-1 normal Osteopenia = T -1 to -2.5, osteoporosis T <-2.5
Bupripion (wellbutrin, zyban) during preg is cat:
cat: B (none in animal but no study in humans (PNC, cephalosporins, Acetaminophen)
What is the non-pharmacologic management of Osteoporosis?
adequate Ca and Vit D, weight bearing exercise avoid smoking and excessive alcohol: 1000-1200 mg D Ca
Tricyclic antidepressants during preg are cat risk:
cat: D
Osteoporosis managment pharm:
T score <2.5, bisphosphanates and teriparatide. estrogen w/ or w/o progesterone raloxifene, risedronate. take on empty stomach w/ 6-8 water 30min before eating or lying down or w/ other meds. SQ PTH is anabolic bone agent
Antimicrobial that is Cat B used in preg infection is:
erythromycin
Fibromyalgia diagnostic criteria
3 or more months of MS apin above and below waist line bilaterally, w/ pain on palpation of tender points, profound fatigue, sleep disturbance rare after 55
PNC are preg cat risk:
Cat: B
Fibromyalgia signs and sx
>3m sx unexplained w/ other dx, fatigue, sleep disturbance, female 20-65, impared socail occupationa, depressive/anxiety, exclude statin causes
What uropahtogens are capable of reducing urinary nitrates to nitrites
E. Coli, Proteus spp., Klebsiella pneumonia
Fibromyalgia Points of tenderness
suboccipital muscle, middle upper trapezius, under lower stemomastoid near 2nd constochondral junction, origin of supraspinatus, 2 cm distal to lateral epicondyle, upper outer glueal, greater trochanter, medial fat pad of knee
In Preg asymptomatic bacteruria should be:
Tx to avoid complicated UTI
Fibromyalgia diagnostic test
ESR, C-reactive protein, CK, TSH, CBC, renal Nd LFT
Common UTI organism in preg
E. Coli
Patient with medial knee pain and dx of arthritis would have pain..
medially along the joint line
Length of antimicrobial for preg w/ asymptomatic bacteria
3-7d
The most common site of osteoarthirits is what part of the hip
Anterior especially if it radiates into the groin
What does teratogenic?
substance that has potential to create a characteristic set of malformation in fetus
What is the classic finding in de Quervain's tenosynovitis (extensor and flexor tendons of the thumb)
Positive Finkelstein test.
pain may radiate up the forearm
When is the teratogenic period:
between day 31 and 81 following last menstral period: organanogenis is taking place
Findings of RA included
Morning stiffness, postitive rheumatoid antigen, antinuclear antibodies
What are three factors in drugs passing through the placenta
lipohilicity (higher the easier)
Molecular weight <500g/mol
maternal drug levels
What does the "get up and go" test in elderly test.
Fall risk through musculoskeletal function
Can a preg receive insulin or heparin?
Yes because they have higher molecular weight that can not pass through the placenta
Osteoarthritis pain first line of treatment
exercise if this doesnt work then tylenol for pain: NSAID work better but have higher S/E risk an dshould no be used
Which is better during preg: benadryl or claritin (loratadine)
Claritin: more hydrophilic so causes less S/E to fetus
SPRAINS Grade
Stage I
Stage II
Stage III
I- mild tenderness and edema able to bear weight.
II-moderat pain edema, tenderness, ecchymosis, weight barin painful but can walk
III: tear of ligament, joint instability, sever pain ,unable to weight bear. XRAY
Define Preg Cat B, C, D, X
B is best , C w/ caution, D for danger, X (cross the drugs off the list)
Ottawa ankle rules help determine
whether x-ray is needed w/ suspected ankle injury
Why is bronchospasm worse between 29-36 wks in preg?
increase esophageal irritation from GERD: esophageal sphincter loosens due to increase pressure
Anterior Drawers Test for what
ACL injury laxity or movement
What cat are inhaled (and oral) corticosteroids and Beta agonist in preg: B, C, D, X
cat: C no proof human injury but some in animals
Which of the rotator cuff is most susptible to injury
Suproaspinatus (arm drop test)
What is the preventative tx for N/V in preg
tx H. pylori, ginger, Ca antacid q2hr for 2-3d. B6 is preventative
The mainstay for initial treatment of early OA
Tylenol max of 4g/d unless on warfarin then 2500mg
What is the tx for migraines in preg
tylenol and nsaid (except term due to risk of antiplatelet effect)
What is another pain medication that is a non-steroidal used for moderate pain in OA
Tramadol (Ultram)
What can be used for migraine during preg to attenuate HA sx
lidocaine 4% to affected nostril
What common GYN medication is used to decrease osteoporsis
Estrogen w/ progesterone if they still have uterus
What meds can be given to preg w/ major depression?
serotonin and dopamine receptor modulators, tricyclic and benzo
What medication reduces the risk of methotrexate hepatotoxicity
Folic acid
Bupropion (dopamine receptor modulator) is a cat B , SSRIs are cat C. Should you switch to bupropion during preg.
No. switching can increase depression
Injuries to the ends of bone versus sprains is most common in what age
children
How do you taper down SSRI to prevent w/drawal syndrome
taper 25% of total dose over a week
What is the best screening for Osteoporosis
bone mass densitormetry usin DEXA
What are the S/E of SSRI w/drawal:
jitteriness, nausea, sleep disturbance: worse w/ fluoxetine (longer half life)
What does the spurling Test test for in a MS examination
cervical radiculopathy
How long can effects of SSRI last in fetus
30days may cause w/drawal such as irritability protracted crying shivering
Who should initiate immunosuppressive therapy (mehtotrexat) for an RA Patient
rheumatologis for diagnosis confirmation and initiation of DMARDS.
Tricyclics and benz are what cat for preg
Cat D rarely prescribed during preg
What Gout medication is better for those with renal impairment
Uloric and lower doses are needed to achieve resuls
Taper dose down all benzo prior to preg by 25% week to prevent
w/drawals of tremors, hallucination, seizures, delirium termens
What diagnostic is used in suspected spinal stenosis
MRI of the spine
What are sequela events that can occur from asymptomatic bacteriuria, in preg
acute cystitis, pyelonephritis, UTI
What is the heart sound of soft first heart sound, w/ pansystolic apical murmur that radiates to axilla
mitral regurgitation
Why should a urine culture be obtain in all women early in preg?
Risk of UTI from asymptomatic bacteriuria.
Abdominal exam: high, midline abdominal pulsation of low amplitude that are directed forward indicates:
a normal finding
Define Hales lactation risk cat:
L1 and L2
L1: safest (cromolyn, APAP, depo (1m post birth)
L2: safer, limited study: nitrofuratoin, cephalosporins, 2nd gen antihistamines, prednisone, SSRI
Swollen, non-tender scrotum for 1 wk w/ mass in tunica vaginalis transilluminates is a:
hydrocele
Define Hales lactation risk cat:
L3 and L4
L3: mod safe, no controlled studies or limited: TMP-SMX, Fq antibiotics, 1st gen antihistamines
Generalized, non pururitic skin eruption intermittent exacerbation for years. erythematous plaque on gluteal fold scales and fissuring:
psoriasis
Define hales lactation risk cat: L5
contraindiated: radioactive isotopes, cocaine
Depressed mood, characteristics of nonpsychotic depression include:
early morning awakening and slowed thinking
What wk in preg is preeclampsia noted?
20th
Woman 24wks pregnant what is the fundal height
24cm or 3cm above umbilicus
What are risk factors for preeclampsia?
age <16->40, first preg or first pre w/ new partner, pregestational diabetes, presense of collagen vascular, HTN, Renal, FHx,
Drug most likely to increase lipoprotein levels
hydrochlorothiazide: older beta blockers increase lipids
What are sx of severe preeclampsia?
BP >160/110, proteinuria (>5), hepatic, renal or CNS damage
Most common type of joint disease in US
asteoarthtitis
What are the components of HELLP in preeclampsia?
Hemolysis, elevated liver, low platelet and eclampsia
Sx of left ventricular heart failure
third heart sound, cough , bibasilar rales
What is the most important intervention of preeclampsia?
High suspicion w/ high risk: the OB consult: rest,monitor, antiHTN, anticonvulsant
Eval of rapid, alternating movements of hands assess
cerebellar functioning (assess dysdiadochokinesa)
what is the definitive tx of eclampsia?
Birth
Colic infants patient education: colic will diminish w/:
Time
When does grp B streptococcus colonize typically in preg and when does it trnsfer to fetus?
during 1st wk of preg, and when water breaks or onset of labor
Plantar fat pads on 2y/o child
normal
When should Group Beta Testing in preg occur?
35-37wks: trnsf to baby when labor begins
Test to determine clearance of digoxin.
creatinine clearance estamate
Define Chronic HTN vs Gestational HTN:
chronic: HTN prior preg, prior to 20th wk, persist >6wks post
gestational: HTN after 20 wk but resolving w/in 6wks post
Beta blockers are not contraindicated in ......any more but calcium channel blockers are?
heart failure
Define:
Preeclampsia, Eclampsia
- PreEclampsia: HTN after 20wk w/ protein uria >300mg/24hr and edema
- Eclampsia: PreEclampsia sx w/ tonic-clonic seizures or alt mental status
Low back pain tx
mild activity w/ motrin and rice
HTN Cat in Preg:
HELLP
PreE w/ elevated hepatic enzyme levels and low platelets
In heart failure tx
HCTZ (lasix light), aldactone (spironolactone): aldosterone, angiotension effects.
Are plantar fat pads on 2y/o child?
a. abnormal
b. normal
c. sign of cancer
d. none of the above
b. normal
What does the acronym BATHE stand for in domestic violence?
B:background: home work
A: affect, anxiety: feel
T: trouble: worries
H: handling: support, intervention
E: empathy:
Do diuretics affect pre load or afterload
Pre-load: by decreasing amount of fluid results in heart not working as hard to move blood.
define inevitable abortion?
US w/ viable preg but +vag bleed
What are uses of aldasterone
hyperoldosteronis
Test to determine clearance of digoxin.
creatinine clearance estamate
define threatened abortion?
uterine contents process being expelled
Burn to hands require a referral to a specialist: true or false
true
Beta blockers are not contraindicated in ......any more but calcium channel blockers are
heart failure
Define incomplete abortion?
some portion of product remain in uterus but no longer viable
what is the degree of sedation for antihistamines: atarax
better itch relief and sedation (SE)
Low back pain tx
mild activity w/ motrin and rice
Quantitative serum HcG doubles every ___hrs the 1st wk of pregnancy?
48 hours
Fe anemia before it is tx reticulocytes are (high or low), upon tx it will be (high or low)
low, high (fast 1-2wks)
In heart failure tx
HCTZ (lasix light), aldactone (spironolactone): aldosterone, angiotension effects.
Where are 95% of ectopics located?
fallopian tubes
Do diuretics affect pre load or afterload
Pre-load: by decreasing amount of fluid results in heart not working as hard to move blood.
What is the classic triad of ectopic pregnancy?
abd pain, vag bleed, adnexal mass: but in only 50% of women w/ ectopic
What are uses of aldasterone
hyperoldosteronis
What are the diagnostic for ectopic?
Urine, serum (neg r/o ectopic), see a decrease in expected quant number for age, also US.
Burn to hands require a referral to a specialist: true or false
true
What is salpingectomy (in ectopic preg)
opening of tube and removal of content
what is the degree of sedation for antihistamines: atarax
better itch relief and sedation (SE)
What is definition of spontaneous abortion
ending prior to 20 wks: 60% due to chromosomal defect
Fe anemia before it is tx reticulocytes are (high or low), upon tx it will be (high or low)
low, high (fast 1-2wks)
What is the longest part of labor?
latent phase (2-3days)
When does the first stage of active labor start?
at 3-4 cm cervix
Which are more infections: human, dog, rat
human
When should a preg women be instructed to go the hospital?
when contractions r occuring q 5min.
bouchard nodes versus heberden nodes: define differences
Heberdens are at DIP joint and Bouchards (less common) are at the MIP joint: both are bony "bumps". sign of osteoarthitis
What is the second stage of labor?
the actual birth
Glucocorticoid help with all itis
cellulitis
What is the third stage of birth
when placenta is delivered
which situation would be associated w/ macrocytic anemia
B12 and folic acid
How long is avg labor for first mother?
9hrs, 6 for 2nd and beyond.
what bite would require viral medication
monkey bite
What is a characteristic of type 1 DM: ie what is the blood glucose level and insulin
hyperglycemia and ketoacidosis from lack of insulin (pancreas isnt makin it or enuff)
What is a characteristic of type 1 DM: ie what is the blood glucose level and insulin
hyperglycemia and ketoacidosis from lack of insulin (pancreas isnt makin it or enuff)
Qualitative research:
does not mearsure only states lived experience
What characteristic apply to Type 2 DM: think main risk factors
heredity and obesity
Quantitative research
uses numbers and statistics
insulin G (Lantus) has a short or extended duration of action?
extended duration of action
Independent variable
First thing: it is not being influenced is being manipulated (type of diet)
Lispro (humalog) onset of action occurs in what time:
less than 15min
Dependent variable
change measured in dependent variable: weight is dependent on diet (independent)
What diabetic med should be used w/ caution in sulfa allergy
glyburied (sulfonylureas)
Function of IRB (institutional research board)
review research, be patient advocate, advised of risk and benifits.
What vaccines are required at 4 months?
DTaP
Hib
IPV
PCV
Rota
What is a characteristic of type 1 DM: ie what is the blood glucose level and insulin
hyperglycemia and ketoacidosis from lack of insulin (pancreas isnt makin it or enuff)
What is metformins (glucophage) Mech of action
increases insulin action in peripheral tissue reduces hepatic glucose production
How often does ADA guideline for testing type 2 in asymptomatic >45yrs old
every 3 years
Who can receive live attenuated flu vaccine (nasal spray)
Healthy non pregnant: 2-49
how often does ADA guideline for testing type 2 in <45 years?
only if hx of high-density lipoprotein <35mg or other risk factors
insulin G (Lantus) has a short or extended duration of action?
extended duration of action
What is a characteristic of type 1 DM: ie what is the blood glucose level and insulin
hyperglycemia and ketoacidosis from lack of insulin (pancreas isnt makin it or enuff)
Which vaccine is contraindicated in pregnancy? Injectable Flu, Td, MMR, Hep B
MMR
Lispro (humalog) onset of action occurs in what time:
less than 15min
What characteristic apply to Type 2 DM: think main risk factors
heredity and obesity
What is a criteria for dx of type 2 DM:
plasma glucose level 126mg or higher after 8hr fast on more than one occasion...also now A1C>6.5
What percent of acute Hep B will develop Chronic?
5%
insulin G (Lantus) has a short or extended duration of action?
extended duration of action
Rosiglitazones (TZD) thiazolidinedione mech of action
insulin sensitizer making cells more responsive to insulin: Avandia
What diabetic med should be used w/ caution in sulfa allergy
glyburied (sulfonylureas)
What should be given if some has exposure to Heb B?
HBV and shot of HBIG
What has increase risk of suicide? rifampin, accutane, acyclovir, advair
accutane
Lispro (humalog) onset of action occurs in what time:
less than 15min
What is metformins (glucophage) Mech of action
increases insulin action in peripheral tissue reduces hepatic glucose production
What type of contraception is useful to control acne?
estrogen/progesterone: controls hormone flucuation
What diabetic med should be used w/ caution in sulfa allergy
glyburied (sulfonylureas)
Amniodarone has toxicity to what organ?
lungs
how often does ADA guideline for testing type 2 in <45 years?
only if hx of high-density lipoprotein <35mg or other risk factors
What is metformins (glucophage) Mech of action
increases insulin action in peripheral tissue reduces hepatic glucose production
Which vaccine is effective after one dose? Hep A, Hep B, Gardisil, Herpes Zoster
Herpes Zoster
Gardisil=3shots
Hep B= 2 shots
What is a criteria for dx of type 2 DM:
plasma glucose level 126mg or higher after 8hr fast on more than one occasion...also now A1C>6.5
What is primary Prevention and give an example?
Prevent onset or acquisition of disease:
Ex: immunization, education, use to seatbelts
how often does ADA guideline for testing type 2 in <45 years?
only if hx of high-density lipoprotein <35mg or other risk factors
What is secondary Prevention and give an example?
identify and tx asymptomatic persons who have risk factors for given disease:
Ex: screening, Blood pressure, lipid profile
What is a criteria for dx of type 2 DM:
plasma glucose level 126mg or higher after 8hr fast on more than one occasion...also now A1C>6.5
What is tertiary Prevention and give an example?
Goal of minimize disease complications and negative health from effects:
Ex: meds, lifestyle modification, tx
Rosiglitazones (avandia) (thiazolidinedione) mech of action
insulin sensitizer
What is the incubation period of influenza?
1-4days
Insulin: onset, peak duration of action:
Lispro, Humalog
O: 15min, P: 30-90min, D: <5hr

ultra short-acting, rapid onset
How long are you infectious w/ influenza?
Adults: 5days, Children 10days
immunodeficient shed virus of 3wks
Insulin: onset, peak, duration of action: Regular; Humulin R
O: 1/2-1hr, P: 2-3hr, D: 4-6hr

short-acting
Who is at highest risk of death w/ influenza?
<2 and >65y/o
Insulin: onset, peak, duration of action: Humulin N, NPH
O: 2-4hr, P: 4-10hr, D: 14-18hr

Intermediate acting
What ages can receive the trivalent influenza vaccine?
6months and older and all pregnant women
Insulin: onset, peak, duration of action: Humulin L, Lente
O: 3-4, P: 4-12 hr, D: 16-20: intermediate acting (medicinet.com)
Insulin: onset, peak, duratation of action: Lantus
O: hours, P: none, D: >24hrs

Insulin glargine
Who can receive the Live Attenuated Influenza vaccine?
2years -49 y/o and healthy
What medication can you consider when tx a HTN and DM:
ACE-I: like fosinopril : nephroprotective features
How many doses do <9y/o need for initial influenza vaccine?
2 doses over 4 wks for TIV and 6wks for LAIV
What should be monitored when prescribing biguanide; ie, metformin (glucophage)
creatinine
What are the four antiviral meds approved by the FDA for influenza?
amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), oseltamivir (Tamiflu)
what percent of the body's insuline mediated glucose uptake takes place in the muscle
80%
What influenza medication are approved for influenza A?
amantadine (Symmetrel), rimantadine (Flumadine)
Exercise reduces Insulin Resistance by _____% w/ effects lasting _____Hrs
40% and 48hrs
What influenza antivirals can be used for A and B strains?
Zanamivir (Relenza), oseltamivir (Tamiflu)
What amount of cholesterol does the ADA recommend
300mg or less
What are side effects of zanamivir (Relenza) and how is it administered?
Used to tx the flu:
S/E: bronchospasm (w/ asthma or chronic lung)
Administered via inhalation
What is the Somogyi effect
when insulin induces hypoglycemia and triggers excess secretion of glucagon and cortisol which leads to hyperglycemia
What are the side effects of relenza (Tamiflu) and how is it administered?
GI, n/v; PO take w/ food
What is the dawn phenomenon as it relates to diabetes?
reduced insulin sensitivity 5am-8am due to earlier spikes in growth hormone.
How far apart should MMR be given and how many doses are required?
1m apart 2 doses (live attenuated virus)
sulfonylureas act on what in diabetes
stimulate insulin release from functioning beta cells and enhance insulin sesitivity
Can an MMR be given during pregnancy?
NO
What amount of weight loss is expected w/ metformin
3-5kg in first months of use
What are sequelae illnes of Measles and mumps?
Measles: encephalitis and pneumonia
Mumps: orchitis
What is another advantage of metformin besides DM
It can help improve lipid profile (decrease LDL and triglycerids while increasing HDL)
Can MMR be given when breastfeeding?
YES
What is the major adverse effect of metformin
GI upset: increase dose slowly
How many doses of Tdap should be administered and at what interval?
5 doses: 1st two one month apart 3rd - 5th- 6m apart. Then q 10 yrs
starting at 6wks
What indicated nephropathy in DM patients
Proteinuria: microalbumin (obtain in the morning due to false positive later in the day)
What age should Dtap be administered after entering school?
11-12 y/o
What is the goal of A1C and BP in DM, per 7th JNC report of joint national committe.
<7% and <130/<80
What is the max recommended age for receiving the HIib vaccination
5 years old
Sulfonylurea: M of action and caution
insulin secretagogue

sulfa allergy, renal dysfunction
What immunization should be given at birth?
Hep B
Thiazolidinedion (TZD): M of Action and caution
insulin sensitizer

monitor ALT; hypoglycemia when used w/ sulfonyl or insulin but not solo
List the immunization given at 6wks?
Rotovirus, Dtap, Hib, Pneumococcal, polio
Biguanides (metformin): M of Action, caution
Insulin sensitizer and decrease live glucose production
Caution: Monitor creatinine lactic acidosis risk w/ eleveated CR, hypoglycemia when used w/ sulfony, GI side effect
List immunization started at 12months?
MMR, varicella, Hep A
A-gulucosidase inhibitors: M of action, caution (Precose, glyset)
delay intestinal carb absorption:

Taken w/ meals, help manage postprandial hyperglycemia, GI S/E
When should the final dose of polio be given if not 6m after initial dose?
On or after 4 yrs old
meglitinides: action caution
Short acting insulin secretagogue

Quick insulin burst, before meals, helps postprandial
When should the HPV vaccine be offered and how many doses?
13-18 y/o: 3 doses
Dipeptidyl peptidase -4 (DPP-4) inhibitor: Januvia, Onglyza: MoA?
increase level of insulin, increase sythesis and release of insulin from pancreatic beta cells and decrease release of glucagon from alpha cells.
Dose adjust for renal impair, little hypo risk, use w/ metformin
What does pneumococcal vaccine protect you from?
Invasive disease like meningitis, septicemia from S. pneumonia (leading cause of death from CAP)
What are risk factors of lactic acidosis when using metformin?
renal insufficiency, dehydration, radiographic contrast dye
What medication should an HIV patient receive and how soon after diagnosis?
antipneumococcal vaccine as soon as diagnosis is made
What are medications that causes secondary hyperglycemia
Niacin, corticosteroids, thiazide diuretics
How long after first pneumococcal should second pneumococcal be given?
5 years
How do meglitinide anaologs help w/ DM2:
prevent postprandial hyperglycemia
Which of the following allergic rxn should not receive the Hep B vaccination? egg, bakers yeast, neomycin, streptomycin
bakers yeast
What is the most common adverse effect of alpha-glucosidase inhibitor?
flatulance
When should pregnant women be screen for HBsAg?
At first prenatal visit regardless of HBV hx
Intervention in microalbumin for DM include:
improved glycemic control, strict dyslipidemia control, use of ACE-I or angiotensin receptor blocker.
ACE-I have some nephroprotection
When should a booster dose of HBV be admistered and to whom?
when anti-HB is <10mIU/ml and only for immunocompromised patients
Drugs whose names end in "-pril" and reduce efferent arteriolar pressure are from what class:
ACE-I:
What vaccination should be given to someone exposed to Hep B?
If previously vaccinated: single HBV booster
If no vaccination: HBV and HBIG w/in 24hrs of exposure
What class of meds end in "sartan" and help preserve renal function in DM
Angiotensin receptor blockers
How is small pox spread?
droplets: nasal, oral, pharyngeal
What medications increase your risk of heat stoke?
Med: tricyclic antidepressants (triptylines), beta blockers (lol), vasoconstrictors like decongestants.
Note: meds change the bodies ability to regulate core temp by negating increase CO and vasodilaiton
When is small pox most contagious?
onset of rash: may be w/ fever
What lab should be gotten in a patinet w/ heat stroke
CK to assess muscle damage --> release of electrolyte tissue damage, hyperkalemia
What are sx of small pox?
rash to tongue, open sores, rash to skin all over w/in 24hrs
What can heat stroke lead to..before death?
polycythemia due to volume constriction and hyponatremia w/ Na <120 and stress induced leukocytosis
How long is smallpox contagious?
until all crusts have fallen off
Tx of Heat Stroke
cooling w/ tepid spray and fan vs ice (may cause vasoconstriction decrease ability to lose heat from core), Rhabdomyolysis-->acute renal failure, Ck, creatinine
What is the tx of small pox?
supportive: vaccinate w/in 3 days of exposure lessens severity
62y/o HTN, smoke, Trigly:280, HDL:38, LDL:135 what med is best (class)
multi drug therapy is needed
What age has the greatest mortality from varicella? 2-10, 30-50, 60-80
30-50 years old (fitzgerald)
46y/o HTN smoke, Trig: 110, HDL: 48, LDL: 192, on low-cholest diet what is next best step?
HMG-CoA (coenzyme A reductase inhibitor) (lipitor, zocor, pravistatin) statins
Where does the VZV lie dormant?
sensory nerve ganglia (later causes shingles...dermatone)
64y/o HTN DM2, Trig: 180, HDL 38, LDL: 135. Meds: sulfonylurea, TZD, biguanide, ACE-I, thiazide diuretic what next?
lipid-lowering drug therapy initiated.
What age is varicella vaccine started?
after the 1st birthday and second between 4-6 y/o
What lab should be check w/ taking HMG-CoA reductase inhibitor (Statin) ?
aspartate aminotransferase (liver function), CK
When should pregnant women recieve the first dose of varicella if no immunity?
after delivery and before discharge
What changes are expected when taking fibrates?
increase in HDL: only medication that actually document increase in HDL
What can be given if no immunization but contraindication for vaccination?
VZIG post exposure
What CD4 count in HIV should you withhold live virus?
< 200 cell/uL
How is diphtheria (gram-negative bacillu) transmitted?
usually contaminated liquids ie milk
When prescribing Zetia what should you expect to see?
reduction in LDL
What is the initial sx of diphtheria?
pseudomembranous? pharyngitis
What are risk factors for statin induced myostitis?
advanced age, low body weight, high statin dose
What should you give a patient exposed to tetanus but no immunization?
Tetanus IG
What is the average LDL reduction when only diet is modified in lowering cholesteral tx?
5-10%
How is Hep A transmitted?
fecal oral route: self limiting rarely fatal
When taking atorvastatin and cholestyramine advise the patient to take the medicaiton?
separeate cholestyramine from other meds by 2hrs (affect absorption)
What should clotting factor disorder patinets be immunized with?
Hep A
What medication is most effective against lipoprotein?
niacin
How is polio transmitted?
fecal oral: OPV no longer used in US due to risk of paralytic poliomyelitis
What are secondary causes of hypertriglyceridemia?
hypothyroidism, poorly controlled DM or excessive alcohol
Which would presents > risk for tetanus?
A. puncture while gardening
B: lac while cutting beef
C: human bite
D: abrasion from sidewalk
Puncture wound while gardening
HMG CoA reductase inhibitor (statin)? Effect, comments
lower LDL by 18-55%
Increase: HDL by 5-15%
lower Trig by 7-20%
check AST prior to initiation, & periodically; check CK initiation. not needed further unless sx; A/E: rhabdo, myositis, increase when combined w/ fibrate, renal impairment
Resin (cholestyramine, colestipol, colesevelam): benefits and adverse rxn
low LDL:15-30%
increase HDL: 3-5%
nonsystemic w/ no hepatic monitoring required, minimal effect on Trig (may increase if trig >400)
A/E: GI, constipation, decrease of other meds absorption take >2hrs after
18y/o w/ no primary tetanus should receive what tetanus immunzation?
Tdap now then Td in 1 and 6 months
Niacin (class: antihyperlipidemia): benifits, Use, adverse effects,
increase HDL: 15-35%
decrease Trig: 20-50%
decrease LDL: 5-25%
Highly effective against atherogenic lipoprotein
A/E: flushing (take ASA 1hr prior to reduce), hyperlgycemia, hyperuricemia, GI, hepatotoxicity
Contra: active liver disease, gout, peptic ulcer
50y/o who hasnt had tetanus vaccination in 10 years should receive what tetanus?
Tdap
Fibric acid derivatives: gemfibrozil (lopid), fenobribrate (tricor): what should you expect to see w/ tx and A/E
increase HDL
decrease Trig: 20-50%
decrease LDL 5-20% (if normal Trig) May raise LDL w/ high Trig
A/E: dyspepsia, gallstones, myopathy if taken w/ statin
Contra: sever renal or hepatic disease
What is the most common source of Hep A infection?
contaminated drinking water
What does Ezetimibe (Zetia) do and what are A/Rxn
decrease LDL-C
increase HDL-C
-minimal effect on Trig, prescribe w/ another lipid lowering agent to enhance LDL
A/E: few due to no limited systemic absorption
Which of the following should be tx for acute Hep A? A: interferon-alfa,
B: ribavirin
C: acyclovir
D: supportive care
supportive care
Sedondary hyperlipidemia:
What does inactivity result in
decrase HDL
What age should women start breast exams?
>20y/o if they want
>40 y/o annually
Sedondary hyperlipidemia:
What does Alcohol abuse result in
increase triglycerides, increase HDL increase LDL
What age should women start having mammogram?
40y/o. if high risk annually if low then yearly not recommended
Sedondary hyperlipidemia:
What does DM result in
increase Trig, decrease HDL, increase total cholesterol
When should cervical screening be initiated?
3yrs after intercourse
30y/o q 3yrs after 3 normal
Total hysterectomy: none
Sedondary hyperlipidemia:
What does Hypothyroidism result in
increase Trig increase Total TC
When should endometrial cancer be discussed?
at menopause: report any unexpected bleeding
Secondary hyperlipidemia:
What does High dose thiazide diuretics result in
increase TC, LDL, Trig
What are the five A of tobacco counseling?
Ask, Advise, Assess, Assist, Arrange
Sedondary hyperlipidemia:
What does Chronic renal result in
increase TC and Trig
What medications are used in tobacco cessation?
bupropion (Wellbutrin), varenicline (Chantix)
Metabolic syndrome dx includes:
abd obesity, trig levels higher than 150, HDL less than 40 in men and 50 in women
What does ABRS stand for w/ ENT?
Acute Bacterial Rhinosinusitis
What is characteristic of Metabolic Syndrome related to insulin?
Insulin resistance is present
Things that point to bacterial versus viral sinusitis?
Sx > 4 days, Purulent discharge, tooth or facial pain, maxillary sinus tenderness unilateral, sx worsen after improving.
Describe plasminogen activator inhibitor:
increased levels in atherosclerotic lesion
-inhibits fibrin degradation by plasmin
-enhances clot formation
Purpose of giving decongestant w/ sinusitis is to..?
Promote drainage
Define metabolic syndrome:
3 or more: obesity, blood pressure, dyslipidemia, glucose intolerance
Patient 875mg amoxicillin for sinusitis but worsen after 5days what is the bug? What should you do
it is probably a beta lactam and should use augmentin, tirid gen cephlasporin
What is insulin resistance:
a reduced sensitivity in the tissue to insulins action at given concentration -->subnormal effect on glucose metabolism
Amoxicillin for sinusitis develop hives what should you do?
Stop amoxicillin. Start doxycycline or other none PNC/Ceph
Metabolic syndrome Guidelines:
abd men >40 inches, W >35
-Trig >150, HDL<40
BP: >130/85
Fasting glucose >110
If a patient has anaphylactic on PNC what other antibiotic should not be given?
cephlasporin
Insulin resistance is inversely related to decrease urine clearanc of what
Uric acid (gout)
Adult w/ common cold takes fexoaphenadine (allegra) and fluticosone nasal spray for allergies...what should you do?
keep her on allergy and add oral decongestant. Dont add guifenisin (it wets and fexoaphenadine is trying to dry up)
Tx of insulin sensitizing medication for pt w/ polycystic ovary syndrome can lead to
resumption fo ovulation, fertility, reduced hirsutism
What will oral decongestants exacerbate?
(Psuedofed)...urge incontenance, blood pressure, mitral valve prolapse, BPH
What are some disadvantages to apple shaped (central abd fat)
metabolically active fat, high insulin levels, IR, free fatty acids and high insulin (increase hunger)
What would contraindicated use of topical decongestant? ie affrin
it is a vasoconstrictor: dont use in hypertensive patient
IR contribute to prothromotic and proatherogenic state because
Plasminogen activator inhibitor: inhibits fibrin degradation enhancing clot formation
What is the modified CENTOR score to determine giving an antibiotic for pharyngitis?
fever >100.4, no cough, anterior cervical nodes, tonsilar exudate swelling.
Also: ages 3-14 more likely
>45y/o subtract a number
Seeing a gradual climb in glucose level over years you should consider risk for
metabolic syndrome and DM2
16y/o patient w/ acute pharyngitis and sinus sx but no sore throat only sinus sx but you get positive strep?
PNC 10 days: prevent rheumatic fever
Insulin resistance leads to HTN by increase in:
renal sodium resabsorption-->expand cir volume and incrase vascular resistance
Pt unable to swallow due to throat pain and in sniffing position w/ fever 103, and is spitting? what is the likely dx
epiglotitis
Insulin resistance leads to cardiovascular effects of:
Hypertension through an increase vascular smooth muscle, greater response to angiotensin II and greater sympathetic activation
What is the tx of epiglotitis in a FP clinic?
call 911
Aerobic exercise can reduce IR by what percent
40% and last 48hrs, reduces BP and improves lipids
What the likely hood of having enlarged spleen w/ mono?
50% have enlarged spleen palpate w/ flat part of hand not finger tips
What medication improves insulin sensitivity and metablic parameters like lipids and BP
TZD (pioglitazone, rosiglitazone)
What are mono sx?
FFFL: fatigue, fever, (f)pharyngitis, lymphadenopathy
What does daily ASA do for BP, lipids
counter act proinflammatory and prothrombotic effects of IR
Sx suggestive of mono but mono spot is negative? what should you do?
repeat mono spot in 5-7 days if cont sx. <2% w/ two negative test. Dont do epstein barr virus due to low sensitivity and high cost
What does the WHO define as obesity ___kg/M2 or more
30 Kg/M2
What is kiesselbach plexus?
Anterior nose likely to bleed 90% of nose bleed
How do you treat epistaxis?
topical vasocontrictor (phynlephrine spray), cotton saturated w/ vasocontrictor, insert in nasal opening
What does orlistat do for weight loss
reduc dietary fat absorption by 30%. Results in diarrhea if you eat fats
What if you have epitaxis in rural clinic w/o other resources?
silver nitrate: anesthesia first.
What does Meridia due for weight loss
acts on brain control for mood an dwell being and appetite
Allergic Rhinitis: management
first line: nasal steroid (fluticasone), then add antihistamine, then add decongestant, then add leukotriene blocker
When can someone consider Bariatric surgical:
100lbs or more over ideal or >40BMI
What is the difference in first gen and send gen antihistamines?
second gen is less drowsy and last 24hrs:
zyrtec is 2nd gen but does cause drowsines
What are risk factors for pancreatitis:
hyperlipidemia, abd trauma, thiazid diuretic use, alcoholism, gallbladder stones,
Patient w/ insect sting and allergic sx of runny nose, erythema, puritis at sight what should you use to tx sx?
systemic tx: diphehydramine liquid (absorbed faster than tablet)
What lab is obtained to determine acute pancreatitis
serum lipase level w/ amylase
Patient dx w/ Otitis externa what is a classic sx?
tragus pain, otic discharge, diminished hearing...should NOT have fever (not a systemic disease)
What is the most reliable test for pancreatic cancer
MRI is the most reliable diagnostic.
What is care of pancreatitis
parenteral hydration , analgesia, gut rest, tx underlying cause
Cermumen impaction would produce what type of hearing lose?
Conductive hearing loss (as does any obstruction)
How does a pancreatic cancer present:
abd pain , weight loss, anorexia, N/v, jaundices
What is a sensorineural hearing loss?
8th cranial nerve, effects inner ear, involves nerve
Amylase in Acute Pancreatitis will appear ______ and return back to normal ______. What % are due to cholelithiasis vs % due to alcoholic pancreas
* appears 2-12h after sx onset
* back to normal w/in 7d of pancreatitis resolution
* Amylase level >1000 U/L
*80%=Dx cholelithiasis
*6% = Dx alcoholic pancreatitis
What is presbycusis?
hearing loss from age...bilateral
Amylase: What effects amylase levels
Nonpancreatic amylase:
*salivary glands
* ovarian cysts
* ovarian tumors
* tubo-ovarian abscess
* ruptured ectopic preg
* lung cancer
What does the Webber test detect?
unilateral conductive and sensioneural hearing loss
Riene (mastoid bone then air)
Webber (top of head)
What steps should be taken for eye complaints?
Visual acquity, slit lamp, if only a light look at the side for smooth round globe, flouresceine stain for break in cornea
Lipase in Acute Pancreatitis:
Lipase appear how soon after onset and peaks at what time frame
* appears 4-8h after sx onset
* Peaks at 24h, decreases 8-14d of pancreatitis resolution
What is associated w/ cataracts?
decrease night vision, decrease vision, double vision, decrease color vision.
What non pancreatic reasons would result in elevated Lipase?
* renal failure
* perforated duodenal ulcer
* bowel obstruction
* bowel infarction
Conjuctivits: why are meds given?
only to get back to work or school earlier...they will clear on own
Hyperthyroidism: signs and sx
Characteristics (patho)
excessive energy release, rapid cell turnover
What is a pinguecula?
non-cancerous growth of the clear, thin tissue (conjunctiva) that lays over the white part of the eye (sclera)
Hperthyroidism: signs and sx
Causes (disease names)
Graves, thyroiditis, metabolically active thyroid nodule
Corneal arcus is what?
seen in older patients, may indicate elevated cholesterol
Hperthyroidism: signs and sx
Neurologic: sx
Nervousness, irritability, memory problems
Hyphema is what?
bleeding in anterior chamber (emergency) caused by trauma
Hperthyroidism: signs and sx
Weight
weight loss (modest only in 50%)
What is a chalzion?
hard nontender nodule on eyelid
Hperthyroidism: signs and sx
Enviornmental response
Heat intolerance
What is a stye or hordoleum?
bump on eyelid that starts off tender
Hperthyroidism: signs and sx
Skin
Smooth, silky skin
Hyperthyroidism: signs and sx
Hair
fine hair w/ freq loss
RUQ abdominal pain is associated w/?
Liver disease, choly, pneumonia
Hyperthyroidism: signs and sx
Nails
thin nails that break w/ ease
What is the LES tone related to GERD?
Lower esophageal sphincter, becomes relaxed which results in gastric juice back flow
What is Barretts esophagitis?
Pre malignant condition of the esophagus: a differential of GERD tx w/ PPI: age 50 get scoped, or not responsive to PPI, pain or bleeding get scoped too
Hyperthyroidism: signs and sx
GI
frequent, low-volume, loose stools
GERD tx?
Remain upright 2-3hrs after they eat (clear stomach), pH should be elevated when reflux is expected
Hyperthyroidism: signs and sx
Menstrual
Amenorrhea or low-volume menstral flow
Hyperthyroidism: signs and sx
Reflexes
Hyperreflexia w/ "quick out-quick back" action
What pharm tx is used in GERD?
antacid (reduces pH) (short term 30min but reacts fast),
2nd: H2 blocker (histamine blocker) decrease acid production (dont change pH but work for 12-24hrs)
3rd: PPI the best aggressive tx: (not PRN drug) prescibed for 1 month
Hyperthyroidism: signs and sx
Muscle strength
Proximal muscle weakness
H. pylori is gram negative: causes what?
ulcers in stomach or esophagus,
Hyperthyroidism: signs and sx
Cardiac
Tachycardia
38y/o w/ suspect C-dif (gram neg) what is a classic description of stool?
bloody and watery
What infectious organism is common if under cooked poultry is consumed?
salmonella ( also on pet turtles)
Hyorthyroidism: signs and sx
Characteristics: physiological
Reduced energy release, slow cell turnover
Hypothyroidism: signs and sx
Causes (disease state)
Post thyroididits >90%, primary pitutuary failure (rare), thyroid removal
IBS is dx by:
Rome 3 criteria:
recurrent abd pain 3d/m in last 3m w/ 2 of the following:
relief w/ defecation
onset associated w/ frequency of stool
onset associated w/ form and appearance of stool
Hypothyroidism: signs and sx
Neurologica
lethargy, disinterest, memory problems
54y/o states blood on tissue after BM: what should be done first?
examine rectum, next send to GI
Hypothyroidism: signs and sx:
Weight
Weight gain (5-10lbs)
C/o bloody nocturnal diarrhea w/ fever and cramping: what should you think of dx?
ulcerative colitis (classic sx) inflammatory disease
What age should you start asking about risk of colorectal cancer?
30-40 if high risk then screen q 5 yrs
Hypothyroidism: signs and sx
Environmental response:
chilling easily, cold intolerance
Hypothyroidism: signs and sx
Skin
Coarse, dry skin
Diverliculosis means you have some diverticula when they become inflamed you have diverticulitis: where is the pain?
left lower quadrent
Hypothyroidism: signs and sx
Hair
thick, coarse hair w/ tendency to break
What is the diagnostic test for diverticulitis?
CT w/ contrast IV or oral
Hypothyroidism: signs and sx
nails
thick, dry nails
Pt has inspiratory pain on palpation of RUQ: what is it and what is the dx?
Murphys sign, cholycystitis
Hypothyroidism: signs and sx
GI
constipation (slow down everything)
In classic appendicitis the point of maximum tenderness is called?
McBurneys point
Hypothyroidism: signs and sx
Menstrual
Menorrhagia
What exam should be performed in 26y/o female w/ RLQ pain?
rectal and pelvic exam
Hypothyroidism: signs and sx
Reflexes
hyporeflexia: Slow relaxation phase, "hung up" reflex
Liver function test include:
ALT, AST, (just looking at the liver).
PT, albumin (how well liver is making things).
Hypothyroidism: signs and sx
Muscle strength
no change
What does ALT and AST mean if elevated?
if alt is the higher of the two then they have hepatitis.
If ast is higher think (acetominophen, statins and tequila) both are elevated (things consumed
Hypothyroidism: signs and sx
Cardiac
bradycardia (in severe cases
Pt feels bad he has fever and malaise: AST is higher what is the likely cause
acetominophen, statins or tequila (alcohol abuse)
Pt lab values of ALT 290, AST 100 what is the probable dx?
viral hepatitis
Hyperthyroidism: signs and sx
Hair
fine hair w/ freq loss
75y/o w/ multiple myoloma (long bone pain elevated Ca) could exhibit what?
2/3 found after fx: anemic, dump protein in urine (elevated alkaline phos) : liver enzyme elevated due to cancer of bone cancer of liver, bone disease (unless adolescent or pregnant then alkaline phos is elevated)
Hyperthyroidism: signs and sx
Nails
thin nails that break w/ ease
5 causes of viral hepatitis are what?
Hepatitis A&E transmitted from food, water
Hepatitis BCD transmitted from blood (can be chronic)
Hyperthyroidism: signs and sx
GI
frequent, low-volume, loose stools
Mechanism of transmission of A is?
fecal oral
Hyperthyroidism: signs and sx
Menstrual
Amenorrhea or low-volume menstral flow
Hyperthyroidism: signs and sx
Reflexes
Hyperreflexia w/ "quick out-quick back" action
Hepatitis marker: immunogobulin: IGM (minute you get infected you make it) IGg (after infection gone) (antibodies)
learn this
Hyperthyroidism: signs and sx
Muscle strength
Proximal muscle weakness
What does it mean if Igg is positive?
it means they r immune
Hyperthyroidism: signs and sx
Cardiac
Tachycardia
What does it mean if IgM is positive?
they have an infection (what ever your messuring ) right now
Hyorthyroidism: signs and sx
Characteristics: physiological
Reduced energy release, slow cell turnover
What does it mean if IgM and IgG are both negative?
no immunity no illness: if vaccine give it.
Hepatitis B sx typically?
asymptomatic: hepatocellular carcinoma (80% w/ hepatitis B)
Hypothyroidism: signs and sx
Causes (disease state)
Post thyroididits >90%, primary pitutuary failure (rare), thyroid removal
Hypothyroidism: signs and sx
Neurologica
lethargy, disinterest, memory problems
Who/what must develop protocols governing APN practice: Texas?
Delegating physician and APN using 5 factors
1. texas law
2. experience
3. consulation availability
4. input of delegating physician
5. federal regulation
Increased thyroid disorder risk increase in what age grp
elderly
Who must sign protocols?
How often are they reviewed
delegating physician and APN
reviewed and signed annually
Which of the below is a CHD risk equivalent:
a. HTN
b. Cigarette smoke
c. Male>45
d. DM
DM: also symptomatic CAD, PD, AAA >risk of CHD
What lab value for TSH fT4 is most consistent w/ hypothyroidism
normal fT4 and elevated TSH Levels (somthing is wrong w/ the thryoid and the pituitary is trying to compensate by giving more TSH)
Screened for hyperlipidemia via blood draw should be told to:
a. fast 12-14hrs
b. fast 6-8hrs
c. black coffee allowed
d. non-fasting not necessary
a: fast 12-14hrs:
maximum effect of eating on tryclycertide leve at 3-4 hrs but peak during 12hr
what is Hashimoto's disease
hypothyroidism from an autoimmune response (most common) resulting in thyroidistis destroying large amounts of thyroid
Class of Med will normalize lipid elevation?
a. niacin
b. fibric acid
c. statin
d. bile acid sequestrants
c: Statin:
What is the most common causes of hypothyroidism
autoimmune thyroiditis next is surgical
What lab value do you expect to find in Graves disease
Low TSH level (thyroid overproduction makes pituitary slow down in production of TSH w/ feed back mechanism)
Which test listed below may exclude secondary cause of hyperlipidemia?
a. cbc
b. urine C&S
c. TSH
d. fasting glucose
C: TSH:
and diabetes, renal failure, hypothyroidism
What is a physical finding in graves related to the eyes
Eye LID retraction (appears eye are bulging)
How often are statins taken to lower lipids?
a. twice daily
b. always w/ food
c. w/ ASA
d. in conjunction w/ diet and exercise
D: in conjunction w/ diet and exercise:
(only once daily)
What is the mechanism of action for radioactive iodine in tx of Graves
destroy overactive thyroid
Pt taking lovastatin for 3m for hyperlipidemia w/ muscle aches in thigh. What should be done?
a. stop lovastatin immediatly
b. check liver enzymes
c. order CPK
d. ask about night cramps
c. order CPK: c/o myalgias consider rhabdomyolysis if elevated THEN stop lovastatin immediately
HTN pt most likely to have adverse BP effect from excessive Na?
a. 21 asian
b. 35 menstruating female
c. 55 post menapausal
d. 70 african American male
d: african American male:
What is useful in tx tremor in hyperthyroidism?
propanolol (beta blocker)
T4 for elderly dose should be what compared to middle age adult
75% or less
HT and MI 6yrs ago w/ mild SOB today. takes quinapril, ASA, metoprolol, statin: What sx is NOT indicative of CHF exacerbation?
a. fatigue
b. HA
c. Orthopenea
d. cough
b: HA:
What do you suspect on thyroid scan that reveals thyroid mass (cold spot):
thyroid cyst
CHF on ACE-I. W/ cough. What finding distinguish etiology of cough from CHF?
a. dry nonproductive
b. wet worse w/ recumbence
c. purulent and tachycardia
d. SOB after cough
b. wet and worse: usually worse at night too
What lipid value do you find in untreated hypothyroidism
hypertriglyceridemia
SOB w/ CHF. What test would help determine this?
a. Echo
b. BNP
c. EKG
d. BUN
b: BNP: >80% pg/l = 98% chance of CHF
Class of med used to tx systolic dysfunction post-MI:
a. loop diuretic
b. beta blocker
c. ACE-I
d. thiazide diuretic
c. ACE-I: prevent LV hypertrophy, dilation and dysfunction = prevent HF
U find painless thyroid mass and TSH level less than 0.1 (low) what is the causes
autonomously functioning adenoma
Ramipril initiated at low dose in patient w/ CHF. What is most important to monitor in about one wk:
a. HR
b. BP
c. EKG
d. K level
d; potassium level:
ACE-I work on kidney and may impair renal excretion of K: monitor BUN, Cr one wk after starting
Fixed, painless thyroid mass w/ s of hoarsness and dysphagia what should you consider:
thyroid malignancy
What med could exacerbate CHF?
a. metoprolol
b. furosemide
c. metformin
d. acetaminophen
a. metoprolol: cardioselective BB slow HR, inhibit pt w/ CHF to have increase HR to compensate decrease CO.
What is cost effective to determine malignancy from benign thyroid nodules
fine-needle aspiration biopsy
What is a side effect of excessive levothyroxine (synthroid)
Bone thinning
75y/o HTN takes ACE-Ithiazide diuretic daily. BP 128/88, p: 98. Has dyspnea on exertion and peripheral edema:
a. need better BP manage
b. development of CHF
c. noncomplinace w/ medications
d. fluid or Na excess
b: development CHF:
When should TSH be reassessed when tx w/ synthroid (levothyroxine) is altered
6-8wks
Medication which produce exercise intolerance w/ HTN is:
a. HCTZ
b. amlodipine
c. metoprolol
d. fasinopril
c. metoprolol: decrease HR = exercise intolerance HR cant increase for CO
U find 3cm round mobile thyroid mass, US reveals fluid filled structure dx is
thyroid cyst
Pt w/ HTN has allergy to sulfa. Which med is contraindicated in pt?
a. ramipril
b. metoprolol
c. HCTZ
d. verapamil
c: HCTZ: sulfa med also avoid loop diuretics
Which is best choice of anti-HTN?
a. BB for 38y/o DM
b. ACE-I for pt on K sparing diurectic
c. BB in 46y/o w/ migraines
d. diurectic pt w/ gout
c: BB in 46y/o migraines: Beta Blocker can be used on migraines
A patient w/ downs syndrome should periodically be monitored for what endocrine disorder
hypothyroidism
What do you expect to find in elderly w/ hyper or hypothyroidism
atypical presentation: typically lab values identify disease
Pt poorly controlled HTN for 10yrs. Indicate mostly likely position of his point of max impluse:
a. 5th incercostal mid-clavicular
b. 3rd ICS MCL
c. 5th ICS, left of MCL
d. 6th ICS, right MCL
c. 5th ICS, left MCL: left vent hypertrophy may displace apical impulse
What is the purpose of thyroid hormone physiologically (basic)
assist cell in energy releasing activities
Pt newly dx w/ HTN taking rampiril. What test would be important to monitor?
a. INR
b. Ca
c. K level
d. ALT/AST
c: potassium level
Pt w/ HTN takes 25mg HTCZ QD for 4wks. BP decrease from 155/95 to 145/90. What should you do next?
a. cont HCTZ
b. increase HCTZ
c. add another class to current HCTZ dose
d. stop HCTZ start different class
c. add drug from another class to current med
: still need to decrease BP: combo effects decrease BP
What medication can causes a alteration in iodine metabolism=hypothyroidism
lithium, amiodarone
enlarged atrium or ventricle is important w/ audible murmur. Which study helps eval hypertrophy?
a. chest xray
b. ECG
c. Echo
d. doppler US
c: ECHO
What is the most sensitive and specific thyroid test
TSH (produced by anterior pituitary)
Valve most commonly involved in chronic rhematic heart disease?
a. aortic
b. mitral
c. pulonic
d. tricuspid
b: mitral most common, aortic 2nd most common, pulmonic 3rd most common
What is the negative feedback loop in thyroid pituitary function
TSH output is determined by amount of circulating T4
Pt w/ audible diastolic murmur best heard in mitral listening point no click. Murmur is probably?
a. mitral valve prolapse
b. acute mitral regurg
c. chronic mitral regurg
d. mitral stenosis
d. mitral stenosis:
audible click typical in MVP
What is the most helpful test in confirmation of an abnormal TSH level
fT4- it reflects the function of the thyroid gland. So TSH first the T4 (usually obtained together) but too many things cause variation in T4 to for it to be significant by itself
28y/o grade 3 mumrur. Which one needs referral?
a. fixed split
b. increase in splitting win inspiration
c. split S2 w/ inspiration
d. changes in intensity w/ position
a. fixed split is ALWays abnormal
Is TSH increase or decreased in hypothyroidism
Increased (it is trying to compensate due to decrease feedback of T4)
Is TSH increased or decreased in hyperthyroidism
Decreased (thyroid is putting off extra T4 so pituitary decreases amount of TSH)
25y/o w/ aortic stenosis. Etiology of AS is probably?
a. congenital
b. rheumatic
c. acquired calcific
d. unknonw
a. congentialt: most likely w/ age
b. rheumatic: 2nd most common
c. acquired: >65y/o normal
How do you confirm hyperthyroidism if TSH is low or undetectable?
obtain fT4:
(if it is high then the feedback is decreased)
Most common arrhythmia resulting in valvular heart disease?
a. a fib
b. SVT
c. VF
d. heart block
A: A-fib:
Pt dx w/ tina pedis. Microscopic exam would reveal?
a. hyhae
b. yeast
c. spores
d. comboof hyphae and spores
a. hyphae: also in corpus and cruris
What medication is given w/ low T4 (hypothyroidism)
synthroid (levothyroxine)
What is the age of onset of Graves
20-40 years
(may have underlying like pernicious anemai, myasthenia gravis, DM)
Test used to dx shingles if clinical is questionable?
a. Tzanck prep
b. viral load
c. rapid herpetic
d. CBc
a: txanck prep: taken from blister: most blistering eruptions are herpatic until proven otherwise
What is the clinical presentation of graves?
diffuse thyroid enlargement, exophthalmos, nervousness, tachycardia, heat intolerance
Most common skin cancer?
a. squamous cell carcinoma
b. basal cell carcinoma
c. malignant melanoma
d. cutaneous carcinoma
b. basal cell carcinoma:
Poison ivy x 3 d. She asks about spreading it to family. you state:
a. yes, after crusting occurs
b. yes, fludi in blister can be transmitted
c. no, transmission does not occur
d. no, you'b progressed beyond transmission
c. no: exposure is from contact of plant
What does a thyroid scan reveal in Graves?
Large (hot) gland w/ heterogeneous uptake
Topical hydrocortisone cream most appropriate in pt dx w/
a. psoriasis
b. impetigo
c. atopic dermatitis
d. eczema
d. eczema:
a. topical not strong enough to penetrate psoriasis
b. contraindicated in impetigo
c. emollient best for atopic
What are tx of graves:
Methimazole, propylthiiouracil or radioactive iodine or removal of thyroid
(then tx hypothyroidism)
Skin lesion fluoresces under Woods lamp. What microscopic findings is consistent w/ this?
a. clue cells
b. herpes simplex
c. spores
d. leukocytes
c: spores = fungal infection
What do you expect the lab values to be in hypothyroidism
Elevated TSH and normal fT4 (subclinical)
When should u initiate tx of hypothyroidism?
When TSH rise above 10mU/L (normal 0.5-4) even in presence fo normal fT4
17y/o w/ nodulocystic acne employed as cook. What is greatest positive impact in managing acne?
a. retin a plus minocycline
b. benzoyl peroxide plus erythromycin
c. isotretinonin
d. change occupation
c. isotretinonin (accutane)
What is the initial dose of synthroid in tx of hypothyroid
75-125 ug (75% or less in elderly)
Pt w/ atopic dermatitis will also have:
a. allergic rhinitis and anaphylaxis
b. asthma and allergic rhinitis
c. nasal polyps and asthma
d. allergic conjunctivitis and wheeze
b. asthma and allergic rhinitis: atopic dermatitis = atopic triad
What do you do if you find a palpable thyroid nodule:
watch and wait if no changes to TSH (may obtain fine-needle biopsy to determine malignancy)
Pt willl take oral Lamisil for fingernail fungus. NP knows:
a. will cure 95% of time
b. topical antifungal w/ work if nail matrix involved
c. Lamisil is potent inhibitor of CYP 3A4
d. toenail fungus resolves faster than fingernail fungus
c: lamisil is potent inhibitor of CYP: caution w/ liver if >2.5 above normal stop
Pt w/ tick one month ago w/ red circle and white center. Now c/o numbness, peripheral paresthesias, poor concentration. what lab test can dx Lyme disease?
a. CBC
b. lyme titer
c. ELISA
d. CSF for spirochete
c. ELISA
BPH affects approx ___% of men by age of 60
50 (90% by 85y/o)
What are sx of BPH
increase frequency decrease force of output, nocturia, sensation incomplete bladder
Herald patch is hallmark finding of what derm dx?
a. erythema infectiosum
b. pityriasis rosea
c. seborrheic keratosis
d. atopic derm
b: pityriasis rosea
What medication cause urinary retention in men complicating BPH
tricyclic, first gen antihistamines (anticholinergic effect)
Pt w/ silvery scales on extensor surface of elbows, knees, back: plaques are red: dx?
a. plaque psoriasis
b. guttate psoriasis
c. atopic dermatitis
d. staph cellulitis
a. plaque psoriasis
Cancer society: pneuomic ABCDE: B stands for?
a. bleed
b. black
c. border
d. benign
c. border
What non pharm causes bladder irritation after intake of:
caffeine and artifical sweetners: do not use if incontence or bladder disorders
Skin lesion which is sold mass described as:
a. macule
b. papule
c. vesicle
d. bullae
b: papule: 1.0cm
What class of med can be helpful in BPH:
alpha1 receptor antagonist (alpha blockers) (note: if HTN too then only added to existing therapy
Pt burned w/ hot water. Has several large fluid filled lesions. What r they called?
a. vesicles
b. bullae
c. erosions
d. dermal abrasions
b. Bullae
What medication helps reduce the size of the prostate by blocking conversion of testosterone to dihydrotestosterone.
Finasteride
Lesion w/ folliculitis might be filled w/?
a. blood
b. pus
c. fluid
d. serum
b. pus
When should surgical intervention be considered in BPH.
recurrent UTI, recurent or persistent gross hematuria, bladder stones, renal insufficiency
Impetigo is characterized by:
a. honey-colored crust
b. silvery scales
c. marlbe lesions
d. wheals
a. honey colored crust
Chancroid is a
(soft chanker) STI: from bacteria H. Ducreyi
Best means to observe for jaundice:
a. skin in diffuse light
b. scarp skin to ID KOH pos lesion
c. observe skin in direct sunlight
d. note the patients sclera
d. note sclera: to see jaundice easily
Treatement of Chancroid is:
Azithromycin (macrolide)
ciprofloxacin (2nd gen fluorquinolone)
ceftriaxone (cephalosporin)
Which following lesions never blanches when pressure applied?
a. spider angioma
b. spider vein
c. pupura
d. cherry angioma
c. purpura; and petichia never blanch due to extravation of blood under skin
What other disease do you expect to find when testing for chancroid (STD)
herpes simplex
60y/o w/ clubbing of fingers. What might this indicate?
a. CAD
b. Cirrhosis
c. lead tox
d. IDA: iron deficent anemia
a. CAD: associated w. hypoxia
What does Chancroid look like?
vesicular pustular lesion painful, soft ulcer w/ necrotic base at point of inoculation.
Pt w/ spoon shaped nails. What lab test should u obtain?
a. LFT
b. CBC
c. Hep B antigen
d. ABG
B: CBC for IDA
What is the causative organism in lymphogranuloma venereum
C. trachomatis 1&3
Which med will not increase photosensitivity?
a. amoxicillin
b. sulfa drugs
c. fluoroquinolones
d. doxycycline
a. amoxicillin: all other will
What are the physical findings w/ lymphogranuloma venereum
lesions fuse and create multiple draining sinuses mainly in the groin
Pt w/ psoriasis w/ topical hydrocortisone cream for years. Now states cream doesnt work? What has happened?
a. rebound
b. tachyphylaxis
c. tolerance
d. lichenification
c. tolerance
What is the tx for lymphogranuloma venereum
tetracycline
Chancroid: causative organism
presentation
H. ducreyi
painful genital ulcer, mult lesion, inguinal lymphadenitis
Pt w/ seborrheic dermatitis. What vehicle most appropriate in hairline?
a. ointment
b. cream
c. lotion
d. powder
c. lotion: due to cooling, drying effect
Chancroid Tx
Azith 1g oral or
Ceftriaxone 250 IM or
Cirpo 500 BID x 3d
What derm area has greatest percutaneous absorption?
a. sole of foot
b. scalp
c. forehead
d. genitalia
d: genitalia
Which of the following is inconsistent w/ otitis externa?
a. tragal pain
b. otic discharge
c. otic itching
d. fever
d. fever (swimmers ear): pseudomonas; local infection
Genital Herpes: organism, presentation
HSV2
Painful ulcerated lesion (w/ primary
Sx triad common w/ infectious mono?
a. fever, pharyngitis, lymphad
b. fatigue, pharygitis, fever
c. splenomegaly, fever, body aches
d. tonsillar exudates, lymphad, HA
a. fever, pharyngitis, lymphad (Centor criteria)
Genital Herpes: Tx
Initial: acyclovir 400 Tidx7-10 or
famciclovir 250 tid x7-10,
episodic:
acyclovir 400 tid x 5d
famciclovir 125 bid x 5d
Suppression
acyclovir 400 bid
Med to avoid w/ mononucleosis:
a. azithromycin
b. ampicillin
c. acetaminophen
d. topical lidocaine
b: ampicillin: beta lactam (PCN) causes rash
Lymphogranuloma venereum: oragnism presentation
C. Trachomatis:
vesicular ulcer lesion, external genitalia w/ inguinal lymphadenitis or buboes
Most common complication of influenza?
a. cough
b. bacterial pnumonia
c. viral pneumonia
d. bronchitis
b. bacterial pneumonia: streptococcus pneumonia
Lymphogranuloma venereum: tx
Doxy 100 Bid x 21d
Nongonococcal urethritis and cervicitis: organism presentation
C. trachomatis
cervitiss, irritative void, mucopurelent discharge
Older adult w/ cerumen: what type of hearing loss?
a. sensorineural
b. conductive
c. presbycusis
d. cholesteratoma
b. conductive:

Sensorioneural = inner ear or 8th cranial, presbycusis = loss w/ aging >60y/o
nongonococcal urethritis and cervicitis: tx
azith 1g PO or dox 100 bid x7d
70y/o w/ hearing loss. which is typical of presbycusis?
a. inability to hear consonants
b. asymmetrical loss
c. inability to hear low pitched
d. pulsatile noise
a. inability to hear consonants
Gonococcal urethritis: organism presentation
N. gonorroeae
irritative void, purulent discharge
Which statement is correct about OM w/ effusion?
a. OME needs tx w/ antibioltic
b. OME precede or follow OM
c. OM is more common than OME
d. OM and OME have fever
b. OME can precede or follow OM
Gonococcal urethritis: Tx
Single dose uncomplicated of Cefixime 400mg PO or ceftriaxone (rocephin) 125mg IM, tx w/ azith 1g single or doxy 100 bid x 7 in chlaymida not ruled out
Which is dx w/ AOM?
a. decreased mobility of TM
b. visible bubbles behind TM
c. fluid an dbulging of TM
d. marked redness of TM
c. fluid and bulging of TM
What do you treat concurrently w/ gonococcal urethrits (GC)
Chlamydia (azith 1g or doxy x 7d)
Pt TM is chalky white mark w/ no complaints is probably?
a. normal TM
b. scarring of TM
c. chronic inflammation
d. pus
b. scarring
Epididymitis (epidimymoorchitis) organism and presentation
N. gonorrhoeae, C. trachomatis
irritative void, fever painful swell epidiymis and scrotum
Which finding is an emergency?
a. fiery red epiglottis
b. sudden hoarseness
c. purulent drainage from ear
d. tragal tenderness
a. fiery red epiglottis
epididymitis: tx
ceftriaxone (rocephin) 250mg IM PLus doxy 100mg bid x 10d
Pt w/ fever and phyryngitis has negative rapid strept test. TC is normal: The patient:
a. has strept and should be tx
b. has bacterial pathogen
c. has pharyngitis but undetermined etiology
d. tx'd w/ PNC due to sx
C. pharyngitis
Trichomoniasis: organism presentation
T. vaginalis:
none or dysuria, strawberry cervix (punctate hemorrhages)
45y/o spinning sensation for hrs before stopping w/ n/v and HA. Which is not sx of benign positional vertigo?
a. length of duration
b. N/v
c. Ha
d. sensation of spinning
c. HA
trichomoniasis: tx
Metronidazole (flagyl) 2g onetime
Pt dx w/ allergic rhinitis. Which sx is NOT associated w/ allergic rhinitis?
a. paroxysmal sneez
b. rhinorrhea
c. nasal congestion
d. facial pain
d. facial pain: indicates infection
Which is most typical w/ allergic rhinitis?
a. normal nasal turbinates
b. cough
c. post nasal drip
d. sx associated w/ expsure to cates
d. sx exposure to cats: dx base on exposure.
a. typically pale boggy
b. common but not all
c. not all
Genital warts (condyloma acuminata): orgnanism presentation
HPV
verruca form lesions or subclincial
Nasal congestion upon exiting building. Occur in spring and summert. Dx?
a. seasonal allergic rhinitis
b.perennial allergic rhinitis
c. chronic non-allergic rhinitis
d. rhinitis medicamentosa
c. chronic non-allergic: tx w/ topical azelastine
a: tree, grass mold
b. dust mite, animal dander
Genital warts (condyloma acuminata): tx
patient applied: polofilox 0.5% or imiquimod 5% cream:
Provider: liquid nitrogen, tricholoacetic acid, surgical or podophyllin resin
Epistaxis most common occure:
a. in women
b. at kiesselbach plexus
c. posterior septum
d. pt on anticoagulant
b. kiesselback plexus: 3 artery
a: more in men
c. 80% anterior
d. common but not most
Acute bacterial prostatitis <35y: organism presentation
N. gonorrhoeae, C. trachomatis
irritative void, suprapubic, perinal pain, fever, tender boggy prostate
40y/o in good health w/ 0.5 white plaque on oral mucosa. no pain. What should you do next?
a. benign lesion: monitor
b. mechanical trauma: monitor
c. biopsy
d. referred to dentist
c. biopsy: leukoplakia precancerous
acute bacterial prostatitis: Tx
Ofloxacin 400mg x1 then 300BIDx10d or
Ceftriaxone (rocephin) 250mg IM then doxy 100mg bid x 10
Pt dx w/ acute rhinosinusitis: etiology?
a. strept
b. staph
c. viral
d. mycoplasma
c. viral: only 2% r bacterial
Acute bacterial prostatits: organism and presentation >35y
Enterobacteriaceae (coliforms)
void, suprapubic perinaeal pain, boggy prostate, leukocytosis
Sx of bacterial sinusitis vs viral?
a. discolored nasal discharge
b. worsenign sx after improve
c. facial pressure
d. nasal conge
b. worse after improvement:
acute bacterial prostatis: tx >35
Ciprofloxacin 500mg bid or ofloxacin 200mg PO qD x 14
Pt w/ healthy eval. States woke this am cant hear out of left ear. Exam is normal: what next?
a. Rx antihistamine & nasal decongestant
b. send to audiologist
c. refer to eNT
d. initiate steroids and consider referral in 1 wk
c. refer to ENT: need MRI: diff dx: acoustic neuromea
Chronic bacterial prostatis: organism presentation
enterobacteriaceae
void, dull,poorly localized suprapubic perineal pain
Pt w/ ears stopped up, blew out forceful after pinching ears. Dx w/ TM rupture. What would indicate this?
a. bright red blood
b. pain
c. clear fluid
d. absence of hearign
a. bright red blood
d: hearing muffled
What is the difference in epididymitis in younger vs older men
older men: secondary to prostatitis
younger: STI: C. trachomatis or N. gonorrhoeae
Pt w/ sensation of something in throat. normal exam. What dx?
a. factition sore throat
b. pseudo pharyngitis
c. globus
d. Gerd
c. globus: most common cause is GERD
What is Prehn sign in epididymitis?
reduction in pain when scrotum is elevated above symphysis pubis
Pt w/ viral URI cannot spread to others via?
a. hand contact
b. droplet transmission
c. fomites
d. urine or stool
d. urine or stool
What is epidiymoorchitis:
both testicles involved swelling so two cannot be distinguished
Pt dx w/ strept throat tx w/ amoxicillin. No improvement in 48hrs. What next?
a. wait 24 more hrs
b. change to 1st gen cephalo
c. macrolide should be Rx
d. PNC or cephlo w/ beta lactamase should be considered
d. PNC w/ beta lactam
c. macrolide has poor resistance to strept
epidiymoorchitis: mainly caused by UTI: What is the diagnostic test to determine tx?
urine culture
Pt given PNC V 3xd for 10 d sore throat. On day 9, feeling better but puritic full body rash? What is clinical finding?
a. rash will be fine and popular
b. hives
c. large, splotchy, non-pruritic
d. rash will not blanch
b: hives: puritic, circumscribed, raised red w/ central wheel
37y/o w/ gram neg cocci, dysuria, urethral discharge what is likely organism:
N. gonorrhoeae
Pt w/ PNC allergy. Which would help determine whether to give cephalosporin?
a. ever taken cepholosporin
b. how long ago was rxn
c. what kind of rxn
d. what form of PNC
c. kind of rxn: 2% w/ PNC rxn have cephlo rxn
Tx option for gonococcal proactitis is
ceftriaxone, 125 IM
Pt hospitalized w/ CHF. Now c/o hearing loss. Which med caused it?
a. digoxin
b. furosemide
c. ramipril
d. metoprolol
b. furosemide: also aminoglycosides, vanco, e-mycin, loop diurectics, antimalaria..
CDC recommends what single dose for uncomplicated urethritis by N. gonorhoeae?
cefixime (cephlasorin )suprax
29y/o return from camping. Hx of DM1 and migraines. 2d hx of n/v. Whichis least likely cause?
a. migrain Ha
b. DKA
c. AGI
d. Giardia infection
d: giardia infection: causes dirrhea
Risk of transmission from infected woman to male is what percent if single coital act?
20-30%: 60-80% chance man to women
46y/o female low-grade fever and nausea pain at McBurneys pont. Nex action:
a. order a CBC
b. refer to ER
c. prescribe a laxative
d. obtain pregnancy test
b. refer to er for CT scan
What is the incubation period of N. Gonorrhoeae
1-5d
Pt w/ inguinal hernia c/o colicky abdominal pain, n/v: it is likely:
a. hernia that is strangulated
b. gastroenteritis
c. chronic constipation
d. unrelated to his hernia
a. hernia strangulated: emergency surg in 4-6hrs.
Because gonorrhoeae produces beta-lactamase what is the best antibiotic
cephalosporin: ceftriaxone and cefixime
Pt w/ supsected hernia examined:
a. lying down
b. standing
c. side-lying
d. while squatting
b. standing
Tx of chronic bacterial prostatitis should consider treating a gram ____ _____ organism
gram negative rods (e. coli or pseudomonas)
Pt dx w/ Hep A. Most common risk factor:
a. drinking contaminate water
b. eating contaminated food
c. traveling internationally
d. IV drugs
C: traveling international (most)
a & b: most unable to confirm
D: hep C
What are sx of acute bacterial prostatitis:
perineal pain, irritative void, fever

Low back pain in chronic BP
Most pt w/ acute Hep A are:
a. males
b. acute ill
c. varied clinical presentation
d. develop subsequent cirrhosis
c. varied clinical
What does the prostate feel like on exam w/ acute bacterial prostatitis
boggy
Pt w/ following laboratory value. Waht does this mean? Hepatitis A: (+) IgG:
a. has hep A
b. Has immunity to hep A
c. Has no immunity to hep A
d. more data needed
B: has immunity (IgG is antibody
How long should the tx of chronic bacterial prostatitis last and what med is best:
ciprofloxacin for 4wks may need 12 wks.
Pt dx w/ Hep B. Most common risk factor?
a. drink water
b. eat food
c. travel international
d. sexual exposure
d. sexual exposure
What is the best diagnostic test to ID offending organism in bacterial prostatitis
urine culture
Most pt w/ actue hep B:
a. females
b. acute ill
c. varied clincial presentations
d. develop subsequent cirrhosis
c. varied presentation
a: = to males
b: fever, nausea, flu-like
What does a digital rectal exam of prosate cancer find
prostatic induration
Pt w/ pos Hep B surface antibody: means:
a. acute hep B
b. chronic hep B
c. immune to hep B
d. needs immunization to hep B
c. immune to hep B
A PSA will ____ w/ prostate cancer
double in serial annual test w/ normal prostatic exam
Pt w/ Hep C:
a. receive imminization for hep A
b. receive immun for hep b
c. receive immun for A&B
d. neither A or B
c. receive immun for A&B
Risk factors for prostate cancer
African, FHx, high fat diet
83y/o dx w/ diverticulitis. Most common complaint:
a. rectal beed
b. bloating and crampiness
c. LLQ pain
d. frequent belching and flatulence
c. LLQ pain
Average American __% life time risk of prostate cancer
40 %
GERD and physiologic reflux simalar except physiolgic reflux:
a. produce mucosal injury
b. nerver occures at night
c. occurs on ly postproandial
d. usually asymptomatic
D: asymptomatic
A: is GERD
What are the findings on testicular torsion?
scrotal pain unilateral loss of cremasteric reflex, swollen tender
What diagnostic test is used in assessing testicular torsion
doppler to determine blood flow: (will be decreased if severe)
Which drug/class most liley to produce rapid relief of heartburn?
a. antacid
b. H2 blocker
c. PPI
d. sucralfate
a: antacid 20-30min
b and c: hrs to work
d: adheres to mucosal wall
Most important risk factor in duodenal ulcer disease:
a. cigarette smoking
b. spicy food
c. coffee consumption
d. inffection w/ H. pylori
d. infection w/ H. pylori: peptic ulcer disease gastric adenocarcinoma and lymphoma
What is orchiopexy and when is it used
Tacking the testicles low in the scrotum to prevent re-occurrence of testicular torsion
Pt w/ gall bladder disease has classic sx. Which sx below is NOT classic of gallbladder?
a. intense, dull pressure mid abd
b. pain radiates into chest, back or right shoulder blade
c. pain worsen after fatty meal
d. pain occurs w/ fasting
d. pain occurs w/ fasting:
Variocele presents w/
"bag of worms" mass in scrotum dissappears when lying down
Which would be unusual in pt w/ uncomplicated gallbladder disease?
a. fever
b. guarding
c. Postive murphys
d. nausea
a. fever: not typical
What is a lab finding w/ variocele
decreased sperm count w/ increase abnormal forms (similar to varicose veins in the legs...weak valves result in increase swelling of veins)
42y/o dx w/ ulcerative colitis years ago. Last colonscopy 5yrs. What screenign is neded for colon cancer?
a. at age 50 w/ colonoscopy
b. now w/ fecal occult
c. now w/ colonoscopy
d. at age 45 w/ colonoscopy
c. now w/ colonoscopy: 45 then every 1-2 yrs
What is tx of variocele ( like varicose veins in scrotum)
scrotal support
Relation betweel colon polyps and colon cancer:
a. polyps all become malignant
b. polyps slow progression to cancer
c. polyps rapid progression to cancer
d. no relationship
b. slow progression
Primary syphilis: presentation, tx
painless ulcer, indurated: lymphadenopathy.
PNC G 2.4m IM if allergy then
Doxy 100mg Bid x 2w
- also tx for secondary syphilis or latent syphilis of <1yr
Single stool specimen during rectal exam is:
a. adequate fro screening cancer
b. detect presence of polyps
c. inadequate to screen cancer
d. adequate for low risk patient to screen cancer
c. inadequate for cancer: need 3
Secondary syphilis: presentation, Tx
diffuse maculopapular rash palms and soles, lymphadenopathy. fever, malaise
Tx: PNC G 2.4M IM allergey to PNC
Doxy 100mg BID or Tetra 500 QID x2wk
Hemorrhoids is unusual if?
a. bleed or itch
b. 45-65 y/o
c. 20-30y/o
d. more common in pregnant
c. 20=30y/o not very common
Later or tertiary: presentation, slide 3 tx
Gumma (granulomatous lesions involveing skin, mucous membranes, bone) aortic insufficiency, aortic aneurysm, Argly Roberttson pupil seizures
PNC G 2.4 M IM weekly x 3 wk or if allergic like secondary:
doxy 100mg BID x 2 wks
70y/o bright red blood on toilet this am after BM. Most likely?
a. hemorrhoids
b. diverticulosis
c. colon cancer
d. colon polyp
a. hemorrhoids
When do lesions present in syphilis
2-4 wks after sexual contact.
50y/o hx of 3-4 alcoholic drinks daily w/ weekend binge has elevated liver enzymes. which is most likely?
a. AST=200, ALT=75
b. AST=100, ALT=90
c. AST=100, ALT=200
d. AST=30, ALT = 300
a: Remember: elevated
AST = actaminophen, statin, toxic,
ALT = liver --> Hepatitis
What is a sequelae of HPV
anorectoal carcinoma
37y/o routine blood work during exam shows Elevated liver enzymes. Physical Exam reveals large tender liver: what next?
a. repeat liver enzymes today
b. order hep panel
c. RTC in 1 wk for recheck
d. order CBC
b. hepatitis panel
What best describes a condyloma acuminatum lesion
verruciform
Pt had acute RUQ pain lasted 3days. Low grade fever. What should be suspected if serum amylase elevated?
a. cholecystitis
b. peoptic ulcer disease
c. diverticulitis
d. pancreatitis
d. pancreatitis: days of pain = enzyme increase 6-12hr after injury
Tx w/ condyloma acuminatum:
imiquimod (aldara) or podofilox
What 2 states are most common w/ pancreatitis?
a. gallstones and alcoholism
b. hypertriglyceridemia and cholecystitis
c. appendicitis and renal stones
d. diabetes and cholecystitis
a. gallstones and alcoholism
What age should you receive HPV for colorectoal carcinoma prevention
13-18
Joints most commonly involved in OA:
a. fingers
b. wrist
c. hips
d. knees
a. fingers
What are common risk factors for ED
HTN, DM, smoking (anything): testosterone deficiency is NOT a risk factor
X-ray of right nee w/ joint space narrowing. What does this mean?
a. patient aging
b. gout
c. normal
d. cartilage is breaking down
d. cartilage is breaking down: risk: advance age, obes, jioint injuries
What is the result of using sildenafil (what is it)
Erection: although sexual stimulation will still be needed to achieve erection: (viagra)
Which test if po is part of criteia for SLE?
a. ANA
b. Rheumatoid factor
c. RPR
d. ESR
ANA: also: butterfly face rash, disoid rash, sun-related rash, painless oral ulcerations, joint pain two or more, heart or lung inflammation
What is the most probable cause of ED in 70y/o
some underlying cause
What medications can causes ED
anti HTN, antidepressants, cimetidine (tagament)
60y/o former college football c/o medial knee pain. Has arthritis in knee. What would pain be located?
a. medially, radiating into upper thigh
b. medially, alnong joint
c. inch above medial knee joint
d. inch below medial knee joint
b: medially along joint line: classic arthritis pain. tears in medial collateral and meniscal.
Pt undiagnosed w/ RA. Which finding should cause suspect RA?
a. morning stiffness, pos RA antigen and antinuclear antibody
b. fever, symmetrical jiont involvement, normal sed rate
c. asymmetrical joint, male pain
d. nodular lesion on elbow, neg sed, pos, antinuclear
a. morning stiffness >1hr, rhematoid nodules, bone erosion on xray, pos sed rate
How does sildenafil or vardenafil work?
enhance effects of nitric oxide: chemical relaxes smooth muscle in penis and allows increase blood flow (take 1hr prior to sex)
The "get up and go: test in elderly used to eval:
a. risk for falls
b. lower extremity strenght
c. mental acuity
d. driving safety
a. risk of falls
What should not be taken w/ sildenifil (viagra)
a nitrate (NTG)
81y/o active w/ OA in R knee. c/o pain. What is 1st line tx. per American colleg of rhematology?
a. exercise
b. acetaminophen
c. ibuprofen
d. propoxyphene
a. exercise
What drug can be injected into the penis for erection or what drug can be inserted in the urethra (ouch)
alprostadial (caverject) or Muse
84y/o femal w. OA to right hip. C/o daily pain. What med is first line tx?
a. naproxen
b. acetaminophen
c. Ibuprofen
d. propxyphene
b. acetaminophen up to 1000mg 4xd
Describe the effects of asthma on the airway
chronic airway inflammation w/ superimposed bronchospasm
Adolescent athlete injured his ankle playing basketball. Right ankle pain,ecchymosis, significant edema, unable to bear weight at time of exam: least likely:
a. avulsion fracture
b. grade 1 sprain
c. grade 2 sprain
d. grade 3 sprain
b. grade 1 sprain
What do you expect to find in an acute asthma flared managed in a primary care (physical exam not lung sounds)
hyperresonance on thoracic percussion
Ottawa ankle rules determine when:
a. inversion ankle injury occured
b. anterior talofibular fx has occurred
c. xray are needed w/ susptected andle fx
d. referral to ortho
c. xray needed: ankle or mid foot pain and bone tenderness. bone tenderness at base of 5th metatarsal or unable to bear weight for four steps when examined
44y/o being tx w/ fluticasone w/ salmeteral (advair) 1puff bid and albuteral 1-2 x wk prn wheeze. Now w/ URI and wheeze what diagnostic should you obtain to assess air flow?
peak expiratory flow (PEF): maximum speed of expired air
When should functional rehab occur after ankle or knee sprain?
a. day of injury
b. 5 days post injury
c. 2-3 wks after injury
d. when pain level allows
a: early function rehabe day fo injury speeds time of recovery and resumption fo activities. : range of motion initially
24y/o asthma flare, using pulmicort and albuterol but cont to have wheeze. PEF 55% baseline you should adjust meds to include
adding a prednisone. For long term control a long acting beta 2 agonist can also be used
Initial managment of sprain:
a. xray
b. rest, ice, compression ,elevation
c. anti-inflammatory med
d. activity as toleration
b. RICE
What do you expect to find on CXR during acute asthma attack?
Hyperinflation (think of wheeze trying to escape)
Anterior drawer test assess:
al injury to lateral menisucs
b. stability of ACL
c. instability of PCL
D. stability fo knee
b. stability of ACL (anterior cruciate ligament): pain not immediate
36y/o w/ asthma and HTN what med should you avoid when tx his HTN
beta blocker (propanolol)
Which sx can r/o fx?
a. degree of pain
b. extent of mobility
c. degree of swelling
d. no sx can r/o fx
d: no sx can r/o fx
Which sx is consistent w/ asthma
nocturnal cough, cough or wheeze after exercise, cold that "got to the chest" or tak >10d to clear
Long distance runner dx w/ tibial stress fracture. What should NP recommend initially to speed recovery?
a. casting,
b. crutches
c. cross-training
d. Ca supplement
c. cross training
What is a corner stone tx of moderate persistent asthma
inhaled corticosteroid
What is most prevalent skeletal problem in US?
a. OA
b. Stress fx
c. osteoporosis
d. Rheumatoid arthritis
a. OA
29y/o female moderate intermittent asthma, not using inhaled corticosteroid but is using albuterol PRN to relieve her cough and wheeze> now using 2 puffs per day you should
discuss excessive albuterol use may increase risk of asthma death
75y/o w/ OA and pain. Which increases GI related ulceration?
a. celecoxib
b. warfarin
c. Thiazide diuretic
d. pravastatin
a. celecoxib
In tx of asthma what should leukotriene inhibitors be used for:
inflammatory inhibitors
16y/o play trumpet daily practice for 1 wk. c/o pain to 3-4th toe of left foot. not swollen or red. What is etiology?
a. strain
b. bursitis
c. stress fx
d. tendonititis
c. stress fx due to over use
How long after inhaled corticosteroids or leukotriene do you expect to see results
1-2 weeks
Pt w/ right shoulder pain 7/10, after acute shoulder injury yesterday. fell against brick wall. pain radiates into upper arm. what rad study should be conducted initially?
a. x-ray
b. CT
c. MRI
D. US
a. xray
Xopenex has what improved benefit over albuterol
greater bronchodilation w/ lower dose
50y/o reports acute pain to lower back 2wks after yard work. radiates down left leg. self tx nsaids. When should you using imaging?
a. now.
b. at 4 wks
c. at 8 wks
d. never
b. 4 wks: unlss hx of cancer, >50y/o neuro deficits, pain inconsistent w/ hx
What are the goals of of asthma care:
minimal or no sx like cough and wheeze especially at night
55y/o sever pain at base of left first toe. Limping but not trauma. which sx is other than gout?
a. pain
b. edema
c. erythema
d. fever
d. fever: signals infection
What is the normal circadian variation of PEF
10-15% from waking to night: w/ asthma it is >15% at night =nocturnal bronchospasm
80y/o very active but presents today w/ posterior hip pain for past wk. Which is least likely part fo differential dx.
a. OA
b. sacroiliac joint disease
c. lumbar radiculopathy
d. herpes zoster
d. herpes zoster
What is the backbone of mild, moderate or severe persistent asthma therapy (3 slides)
use of inflammatory control drug: inhaled corticosteroids (symbicort, fluticasone), mast cell stabilizers (cromyln) and leukotriene modifiers (singulair)
note: Inhaled corticosteroids are the most effective and preferred
75y/o knits w/ positive finkelstein test. Dx?
a. gamekeepers thumb
b. De Quervains tenosynovitis
c. OA of thumg
d. trigger thumb
b. De Quervain tenosynovitis: inflammatoin of extensor and flexor tendon. radiate up forearm
What are the rescue inhaler and why are they used
short acting-beta 2 agnoist (albuterol, levalbuterol) used to relieve acute superimposed bronchospasm
Extrinsic shoulder pain is LEAST likely produced by:
a. CV system
b. abdomen
c. infectious organism
d. urologic system
d: urologic system
In asthma control what is the next treatment when giving a corticosteroid when sx control is not being met:
Add a long acting beta 2 agonist: salmetrol, formoterol
Drop arm test used to assess patient w/ suspsected:
a. cervical injury
b. torn rotator cuff
c. impingement syndrome
d. malingering
b. torn rotator
beta2 agonist have a "-terol" suffix what are some meds and what are their actions
albuterol short acting, and salmetrol long acting: Stimulate beta 2 site causing bronchodilation
Which is not true regardign cervical whiplash injury?
a. occurs after traumatic event
b. may accompany severe pain, spasm
c. Identifiable on MRI or CT but not xray
d. Occipital pain and HA
c. It is not identifiable on MRI or xray
Why should beta-adrenergic antagonist "lol" not be used in asthma?
They can precipitate bronchospasm ie propanolol
NP are certified by:
a. state
b. ANA
c. state boards
d. ANCC or AANP
d: ANCC or AANP:
state boards license NP
Corticosteroids have an "-one" or "-ide" suffix: examples
fluticasone (flovent), prednisone, budesnide (pulmicort)
Which does not influence scope of practice?
a. code of ethics
b. state federal laws gov practice
c. reimbursement rate for visits
d. nurse practice acte
c.: scope of practice is established legally, ethically, and by boards of nursing and professional organizations.
Leukotriene receptor agonist (leukotriene modifiers) have "-lukast" sufix: examples:
montelukast (singulair)
Standards of practice establised to:
a. regulate and control nurse practitioner practice
b. limit liability of NP
c. protect NP from frivolous law
d. promote autonomous practice
a. regulate and control NP practice: provide accountability for professionals and help protect the public
Why is do you hear hyperresonance on percussion and hyperinflation in asthma
because of air trapping, decreased PEF
Licensure:
a. another term for certification
b. contingent on certification
c. used to establish minimal competence
d. necessary for reimbursement
c. used to estab minimal comp
Asthma:
Inhaled Corticosteroids: MoA, indication (three slides)
inhibit eosinophilc action, potentate effects of beta2 agonist
controller drug, prevention of inflammation:
must be used consistently to help
Certification:
a. required by all 50 states
b. validates competence
c. recognized by all 50 states
d. required for reimbursement
b. validate competence: in an area of specialty
Asthma tx:
Cromolyn (intal): MoA and indications
halts degradation of mast cells and release of histamine (MAST cell stabilizer)
- Controler drug, prevents inflammation:
need consistent use but less effect than corticosteriods
NP has a managed clinic for hosp employee, employed by hosp. This NP is described as:
a. intrapreneur
b. entrepreneur
c. risk taker
d. nurse specialist
A: intrapreneur: carved out specialty w/in existing organization. Entrepreneur assumes financial and personal risk of owning
Leukotrien modifier: (montelukast) singulair: MoA, indications
M of A: Inhibit action of inflammatory mediator by blocking receptor sites
Indications: controller drug, prevent inflam
less effective than corticosteroids
best when added on as 2nd tx w/ allergic rhinitis
Oral corticosteroids: MoA, indictations (3 slides)
inhibit eosinophili and other inflammatory actions
-tx of acute inflamation in asthma and COPD
>2wks tx adrenal suppression
NP who owns their own clinic?
a. entrepreneur
b. intrapreneur
c. independent NP
d. networker
a. entrepreneur:
Albuterol (ventolin, proventil,xopenex): MoA, indications
Beta2 agonist; bronchodilation via stimulation of beta2 receptors
-Rescue drug: acute bronchospasm: onset: 15min, duration 4-6hrs
Legal authority to practice as an NP is determined by:
a. state boards of nursing
b. state legislature
c. fed guidelines
d. certification boards
b: state legist
state boards --> scope of practice
Certification board --> met mim requirements
Long acting beta2 agonist: salmeterol: MoA and indications
Beta2 agonist; broncholiation, through stimualation of beta2 receptors
Prevent broncho spasms:
Salmetrol: onset 1hr, druation 12hr.
Name given to subjects in research study who do not have disease or condition?
a. placebos
b. controls
c. case series
d. cross secional
b. controls: commonly employed
Ipratropium (atrovent)
tiotropium bromide (spiriva): MoA and indications
anticholinergic and muscarinic antagonist, yielding broncholdiation
tx and prevent bronchospasm:
onset >30min
best used to avoid rather than tx bronchospasm
NP decided to study grp of pt trying to quit smoking. All take the same med for 60d and RTC q 1xwk for 60d. What study design?
a. non-research
b. cohort study
c. case control study
d. controlled trial
b. cohort: observational study that is prospective in nature. Cohort ask "what will happen".
Case control: looks back (retrospective)
Theophylline: MoA and indications
mild bronchodilation, helps diaphram contract
prevent bronchospasm
Narrow theraputic not used often
NP has HIV. Employed in private clinic: NP:
a. obligated to inform employer
b. obligate to inform pt
c. no obligations
d. under obligation if performing invasive procedure
c. non obligation
what is the therapeutic action of inhaled corticosteroids when tx COPD
reduction in airway inflammation
NP works minor care. Pt w/o insurance w/ puncture wound. Dirty needle suspected. the NP:
a. admin Tetanus
b. prescribe med for HIV exposure despite no insurance
c. no mention possibility of HIV
d. offer to buy HIV med at employee discount
b. prescribe med
What is consistent w/ dx of COPD
FEV1/FVC ratio of less than 0.70
Elderly dementia in w/ daughter and has bruises on arm and posterior. What should NP do?
a. don not report abuse until certain
b. r/o elder abuse
c. report to authorities
d. ask daughter if she is abusing
c. report to authorities
What is found in the airway early stages of chronic bronchitis
excessive mucus production
Pt attacked by cat. 4cm lac to forearm. NP sutured lac which became infected requiring hospitalization. This is?
a. negligence
b. unfortunate situation
c. malpractice
d. poor judgement and malpractice
a. negligence: one fails to exercise care that reasonable person would.
What is found in the airway of emphysema patients
enlargement of air spaces distal to terminal bronchioles
NP states he keeps meds and takes them occasionaly? what is your first professoinal responsibility?
a. report to police and owner
b. report to state board
c. report to state board of pharmacy
d. no professional responsibilty
b. to state board
What is the GOLD tx for COPD guidelines for stages II-Iv COPD
short-acting inhaled bronchodilators
Liability policy which pays claims only during period that policy is active?
a. claims made policy
b. tail coverage
c. liability protection
d. bobtail coverage
a. claims made policy
What is the goal of using inhaled corticosteriods in stage III COPD
minimize risk of repeated exacerbations
What is the most common place for indirect hernia?
a. Hesselbach triangle
b. internal inguinal ring
c. outer inguinal ring
d. abdominal ring
b. Internal inguinal ring
Which cortiocsteriod is most potent:
methylprednisolone, 8mg
triamcinolone, 10g
prednisone 15mg
hydrocortisone 18mg
Prednisone
Which immunizations should a child receive if they have sickle cell?
a. all at a rapid rate
b. all at a normal rate
c. all at a decelerate rate
d. limit the immunization given
b. all at a normal rate/interval
What is the typical organism in acute chronic bronchitis
H. influenzae...also Mycoplasma pneumoniae, Chlamydia pneumoniae, and Streptococcus pneumonia.
What immunization may be given during the first trimester?
a. vaicella and MMR
b. Td only
c. Pneumococcus
d. Hep A&B
B. Td only: live virus should never be given, pneumococcus given in 2nd or 3rd trimester
What is an appropriate antibiotic for a 72y/o HF, acute bacterial COPD who has failed amoxicillin
levofloxacin
40y/o w/ lab values of: HBsAg(-), HBsAb (+), HBcAb (-). Interpret them?
a. had hepatitis
b. has hepatitis
c. should immunize
d. has been immunized
d. has been immunized:
1. Neg Hep B antigen (HBAg) = no Hep B
2. He has + Hep B surface antiody (HBsAb)= immune
3. neg Hep B core antibody (HBcAb)=never had Hep B
What is the appropriate antibiotic for 52y/o w/ acute bacterial COPD exacerbation
azithromycin
25y/o w/ sub actue bacterial epididymitis tx w/:
a. oral quinolone
b. doxycycline
c. anti-inflammatories and analgesic
d. ice and scrotal support
b. oganism is Chlamydia in acute bacterial epididymitis= doxy 100mg BID x 10-14d or longer.
Avoid quinolones: all others will help but not tx
What is the definition of chronic bronchitis:
report of excessive mucus for >3m per year fro 2 years absence of other causes 80% causes by smoking
What is typical sx of GERD?
a. chest pain
b. SOB
c. pyrosis
d. hoarseness
c. pyrosis (heartburn)
What is considered the backbone of COPD therapy
Bronchodilators: Tioptropium bromide (Spiriva) and ipratropium bromide (atrovent) anticholinergic w/ stage II-IV COPD
70y/o aa male c/o pain to back and trunk. CAD ruled out. Ha normocytic normochromic anemia w/ hypercalcemia: dx?
a. multiple myeloma
b. lymphoma
c. leukemia
d. prostate cancer
a. multiple myeloma: neoplastic proliferation in bone marrow
What should you advise all COPD patients to avoid
noxious agents, smoking, irritants, obtain annual influenza and antipneumococcal vaccine
Pregnant pt w/ asymptomatic bacteriuria. What is likely pathogen?
a. klebsiella
b. E. coli
c. staph saprophyticus
d. no pathogen
B. E. coli: should tx this w/ Nitrofuratoin
COPD: Stage Characteristic, treatment
Stage 0
cough, sputum production, no spirometric abnormalities
tx: COPD risk reduction
What is a contraindication to giving MMR:
a. FHx of adverse event after dose
b. fever 104 w/in 72hrs
c. seizures w/in 7days
d. encephalopathy w/in 7 days after immunization
d. encephalopathy is always a contraindication.
Fever of 105 w/in 48hr would be too
COPD: Stage Characteristic, treatment
Stage I Mild
FEV: FVC ratio <0.70
>FEV >80% of predicted w/w/o sx
short acting bronchodilator PRN
-albuterol, pirbuterol, levalbuterol
An elderly adult w/ appendicitis is unlikely to exhibit:
a. generalized abdominal pain
b. Initial WBC elevation
c. UTI sx
d. low grade fever
b. initial WBC elevation: kids and elderly do not get an initial rise in WBC
COPD: Stage Characteristic (what diagnostic do you expect on FEV and what is your treatment?
FEV:FVC ration >0.70
-50%>FEV <80% of predicted
W or w/o sx
REg us of >1 long acting bronchodilator: tiotropium,salmeterol
-short acting bronchodilator PRN
-inhaled corticosteroids if repeated exacerbation
-pulmonary rehabilitation
What is recommendation of administering MMR and varicella?
a. not given on same day
b. given on same day
c. cannot be given w/ flu
d. can only be given w/ live virus
b. should be given on same day: increases their titers when given together. if not together the seperate by 30 days
COPD: Stage Characteristic, treatment:
Stage III
FEV:FVC ratio<0.70
-30%>FEV <50% of predicted
Reguires use of >1 bronchodilator
-Tiotropium/salmeterol
short acting: albuterol
Corticoid if repeated
Pulmonary rehabilitation

Pt w/ 2 fasting glucose of 101 and 114 on 2 seperate days:
a. dx w/ DM2
b. dx w/ impaired fasting glucose
c. further testing before dx
d. get Hgb A1c
b. dx w/ impaired fasting glucose
: fasting glucose between 100-125 fits dx.
COPD: Stage Characteristic, treatment
Stage IV
FEV:FVC ratio <0.70
-FEV<30% of predicted or resp failure or HF
>1 long acting broncho: triotriopium
- short acting: albuteral
-cortico if repeat exacerbation
-tx of complications
-long term o2 therapy
-surgical
Pneumococcal immunization in infants has:
a. decrease episodes of AOM due to H.flu
b. shifted pathogenesis to fewer cases of S. pneumoniae
c. eradicated OM due to .s pneum
d. improved prognosis of AOM
b. fewer cases of s. pneumoniae: PCV7 (prevnar), increased case fo H. Flu due to decrease in S. pneu.
Potency of corticosteroids:
Higher potency (equipotent doese):
Which is highe potency:
Dexamethasone 0.75mg
Betamethasone 0.6-.75mg
Betamethasone 0.6-.75mg
Dexamethasone 0.75mg
US in first trimester help estimate gestational age and:
a. ID placental abnormalities
b. improve maternal outcomes
c. ID fetal malformations
d. reduce later US
c. ID fetal malformations: also detecting multiple fetuses, status of placenta.
Potency of corticosteroids:
Medium potency (equipotent dose)
Methylprednisolone 4mg
Triamcinolone, 4mg
prednisolone 5mg
prednisone 5mg
Pt w/ diarrhea has WBC in stool sample:
a. a misdiagnosis
b. a malignancy
c. food indiscretion
d. bacterial infection
d. bacterial infection: Crohns disease or ulcerative colitis also
Potency of corticosteroids
Lower patency (equipotent dose)
Hydrocortisone 20mg
cortison 25mg
Overweight 76y/o recent DM, long term HTN and hyperlipidemia: Now has A-fib. What other risk do u consider?
a. S3 gallop
b. CHF
c. SOB
d. hypothyroidism
b: HTN and hyperlipidemia increase risk of CHF --> Afib, S3 and SOB r consequences not risk
acute bacterial: COPD: etiology and tx:
Gram-pos and neg respiratory pathogen, atypical
amoxicillin or doxy or cephalo, if failure then
fluoroquinolone or HD augmentin
Pt w/ tinea pedis. What is the microscopic finding?
a. hyphae
b. yeast
c. spores
d. combination of hyphae, spores
a. hyphae: long, thin= dermatophyic infections
Acute bacterial: Chronic bronchitis: what is the organism: what is the tx
Psuedomonas aeruginosa
Tx: Ciprofloxacin, levofloxacin
What should you do to a pregnant w/ Type 1 diabetes regarding screening?
a. screen at 24-28 wks
b. screen early
c. dont screen at all
d. send to OB/GYN
A: screen at 24-28 wks: due to increase placental hormones that increase insulin insensitivity
5MM or larger w/ HIV or other immunosuppression or organ transplant or taking 15mg prednisone = pos or neg TB
positive TB
What medication will exacerbate GERD?
a. verapamil
b. metformin
c. ferrous sulfate
d. ceftriaxone
a. verapamil: CCB: Calcium needed for muscle contraction: lower esophageal sphicter
What is the dx after PPD: 10mm in high risk: immagrants, IV drug, health care, resident housing, correction, homeless, health:
Positive TB
Fundoscopic reveals AV nicking on a HTN pt:
a. incidental finding
b. indicative of long standing HTN
c. Pt should be screened for diabetes
d. refer to ophthalmology
b. indicative of longstanding HTN: when arteries cross veins in eye: Cotton wool exudate = diabetes
15mm or larger in all others including those that appear to have no TB
Positive TB
Who is most common risk factor for developing Hep B:
a. homo
b. drug injection
c. hetero
d. body piercing
c. hetero: any are applicable: but hertero has highest likelihood of disease transmission, most common
Anergy testing in TB
giving skin test of substances other than TB determines weakened immune system
Benazepril (ACE-I) should be discontinued immediately:
a. dry cough develops
b. pregnancy occurs
c. K levels decrease
d. gout develop
b. pregnancy occur: ACE-I: teratogenic effects to renal system
Bacille Calmette Guerin in TB
given in many countries: low risk of causing false-pos
Following medications does not warrant monitoring K?
a. fosinopril
b. candesartan
c. HCTZ
d. amlodipine
d: Amoldipine CCB no need to monitor K:
ACE and ARB cause hyper K
HCTZ: cause Hypo K
Booster phenomenon in TB:
seen in elderly. first TB is neg but next year positive because previous infection long ago boost the immune response
50y/o sensation fo scrotal heaviness. Worse at end of day. Denies pain. Etiology of sx?
a. strangulated hernia
b. inguinal hernia
c. epididymitis
d. hydrocele
b. inguinal hernia:
w/ pain not relieved w/ lying down = strangulated
epididymitis = pain no heaviness
Hydrocele = fluid in scrotum
MMSE ID pt w/:
a. dementia
b. depression
c. behavioral changes
d. delirium
a. Dementia: cognitive evaluation for dementia: orientation, recall, attention, calculation, language manipulation
Two step testing TB is used to:
distinguish booster rxn (caused by TB infection that occured years ago) from rxn caused by recent infection
What is chemoprophylaxis therapy for pos TB but no sx
isonizide therapy and periodic chest xray
Pt who abuses alcohol will exhibit:
a. elevated alkaline phosphatase
b. decreased TSH
c. elevated ALT, AST, GGT
d. elevated AST only
c. ALT, AST, and GGT: significatn abuse when AST 2.5 x >than ALT: GGT may be elevated when AST/ALT normal
Antibiotic for community acquired pneumonia: No comorbidity
azithromycin 5-7d
HCP was stuck w/ neeedle from patient who may have HIV. Rapid HIV was found positive. ?
a. HP is infected w/ HIV
b. Pt is infected w/ HIV
c. further testing of pt required
d. further testing of HP required
c. further testing pt requried: + ELISA always requires f/u test with Wester Blot: HP would be test to estabish HIV at time of stick.
antibiotic for CAP pt cant take macrolide:
doxycycline
How is endocervical specimen collected during PAP smear?
a. after ectocervical w/ broom
b. after ectocervical w/ brush
c. before ecto w/ broom
d. before ecto w/ brush
B: after ecto cervical w/ brush: minimize bleeding from endocervix sample
Antibiotic for CAP in 78y/o w/ COPD
amoxicillin w/ a macrolide
65y/o female w/ breast lump: Normal mammogram 6m ago. What is true about lump?
a. probably breast cancer
b. may not be lump at all
c. likely a fibroademoma
d. probably benign lesion
d. probably benign lesion: still eval for breast cancer, Fibroadenomas common in younger, cyst throughout lifespan
Antibiotic for CAP in 69y/o w/ HF and DM2:
respiratory fluoroquinolone
Topical 5-fluorouracil (5-FU) used to tx:
a. atopic dermatitis
b. hepatitis
c. thalassemia
d. basal cell carcinoma
d. basal cell carcinoma: only on superficial 5% BID x 3-6wks
Antibiotic for CAP in 58y/o w/ dry cough, HA malaise no recent antibiotic:
clarithromycin (biaxin) macrolide, doxy
Pt w/ peptic ulcer disease: sx occure few hours after eating:
a. gastric ulcer
b. duodenal ulcer
c. gastric or duodenal
d. H. pylori
b. duodenal: 2-5hr after eating. Relief by eating/antacid. contrast w/ gastric w/ sx minutes of eating: less relief from antacids
What is a quality of respiratory fluoroquinolone:
activty against drug resistant S. pneumonia (DRSP)
74y/o pt w/ laceration. Last tetanus >10yrs. Completed primary series. What vaccine?
a. tetanus toxoid only
b. tetanus and diptheria only
c. none primary will protect
d. Tetanus, diphtheria, acellular pertussis
b. tetanus and diphtheria: Dtap is for adolescents not elderly.
Drug resistant S. Pneumonia (DRSP) mechanism of resistance:
alteration in protein-binding sites
Pt taking metronidazole for C. Difficile: What should be avoided?
a. excess fluids
b. Vit B12
c. grapefruit
d. alcohol
d. alcohol: produced disulfiram rxn w/ metronidazole wait 72hrs after last dose
H. influenzae mechanism of resistance:
beta lactamase production
P tw/ diarrhea tested for C. diff. How soon should enzyme yeild results (EIA)?
a. 20min
b. 24hrs
c. 3d
d. <1wk
b. 24hrs detect C. Diff toxin no organism.
What is a characteristic of macrolide:
effective against atypical pathogen also beta lactamase (PNC is not effective against beta lactamase)
Difference between cellulitis and erysipelas:
a. organism
b. length of time that infection lasts.
c. tx
d. area involved
d. location: erysipelas upper dermis superficial lymphatic: cellulitis: deep dermis
CAP should be tx w/ antimicrobial for how long according to american thoracic society
5-7days outpatient
Lower leg wound appears infected. Red, warm edematous. Acute onset of pain, sx low grade fever. What is it?
b. Erysipelas: not always upper. Erysipelas has acute onset, cellulitis is slow onset
What are modifying factors for P. aeruginosa
corticosteroid use, strucural lung disease, malnutrition
Asymptomatic carotid arteries auscultate for bruits:
a. bruits indicative of impending stroke
b. bruit indicative of significant carotid stenosis
c. generalized atherosclerosis
d. reflective stroke risk
c. generalized atherosclerosis: symptomatic bruit need immediate attention.
Sudden onset of red eye: sensitivity to light and sensation fo foreign body: no contacts:
a. refer to ophthomolgy
b. tx for viral conjunctivitis
c. tx bacterial
d. observe for 24hrs if visual acuity is normal
a. refer to ophthomolgy for red eye: photophobic sensation fo foreign body.
What is mechanism of transmission in atypical pneuomonia?
cough
What class meds tx benign prostatic hyperplasia and provide immediate relief?
a. Alpha 1 blocker
b. 5 alpha reductase inhibitiorss
c. diuretics
d. analgesics
a. alpha blockers: terazosin, doxazosin, alfuzosin
Risk factors for pneuomina death:
renal insufficency, elderly, comorbidity, immunosupressed
What is an acceptable sputum specimen for gram staining?
few squamous epithelial cells and many WBC
Male taking HCTZ for HTN: sever pain to great toe: dx w/ gout: Which med would be contraindicated at this time?
a. allopurinaol
b. prednisone
c. colchicine
d. indomethacin
a. allopurinol: not for acute gout: only reduces uric acid but cont during attack
52y/o smoker w/ CAP, 3rd day therapy w/o fever, hydrated, feeling better when do you get chest xray
7-12 weeks from now
High purine diet exacerbate gout: Which foods are high purine?
a. coffee
b. eggs.
c. beef
d. bread
c. meat/fish: coffee lower risk, Tea increase gout
62y/o hosp w/ CAP considers what about vaccination
influenza and antipneumococcal should be given now
60y/o c/o lower back apin for 5-6wks: 4/10, no relief w/ change of position: dx:
a. sciatica
b. ankylosing spondylitis
c. disc disease
d. systemic illness
d. systemic illness, like cancer or infection: key is no relief when lying down. old, female >4wks pain.
Why is it labeled community acquired pneumonia?
pt resides in comunity not recently hosp and not nursing home
NP agreed to participate in medicare healht insurance: Medicare only pays 80% how do you collect the other 20%?
a. bill remainder
b. cannot bill remainder
c. collect 100# if billed incident o MD
d. NP resubmit bill for additional payment
a. bill remainder:
What is typical presentation of pneumonia?
Cough, dyspnea, sputum production, pleuritic chest pain,
What med is contraindicated for lone us tx asthma?
a. short acting bronchodilator
b. long acting bronchodilator
c. inhaled steroid
d. oral steroid
b. long acting bronchodilator only when combined w/ inhaled steroid due to increased risk of sudden death.
What may CXR reveal in pneumonia pt
infiltrate patterns and areas of consolidation w/ S. pneuonia
Pt w/ Medicare part A only. What does this mean?
a. your visit will be reimbursed by the fed gov
b. reimbursed only if you bill incident to a physician
c. only hospital visits are covered
d. he desires a cost-effective med.
c. only hospital visits are covered: also covers skilled nursing facilities
If a smoker w/ pneumonia take CXR 7-12 wks after therapy to assess for ?
lung cancer
20y/o screened for TB? presents w/ cough night sweats weight loss?
a. chest x ray
b. TB skin test
c. sputum specimen
d. questionaire about sx
B: TB skin test: chest xray after positive TB, sputum sample for dx not screen.
What is the main organism of smokers w/ pneumonia?
H. influenzae (tracheobronchial tree conlonized
ACE-I specifically indicated in patients who have:
a. HTn DM w/ proteinuria, HF
B, DM, HTN, HLD
C. asthma, HTN DM
d. renal nephropathy, HF, HLD
A: HTN, DM w/ proteinuria, HF: worsen renal insufficiency
How are mycoplasma pneumoniae and C. pneumonia transmited
via cough, in closed community
How would u create a therapeutic relationship w/ patient?
a. Tell patient he can trust you
b. at end of visit, tell patient you enjoyed taking care of him
c. ask open-ended questions
d. touch pt during the interview
c. therapeutic relationship w/ pt can be established in many different ways. Ask open ended questions.
Tx of CAP:
no comorbidity:
macrolide: azithro or clarithro
Alt: doxy if macro intolerant
Pt who frquently has episodes of gout should avoid which sets of food?
a. beans, rice, tea
b. scrambled eggs, milk, toast
c. roast beef and rice w/ gravy
d. fish and steamed veggies
C: roast beef and rice w/ gravy
High purine: beef, pork bacon, lamb, seafood, beer, bread:
Low: fruits and fruit juices, green veggies, nuts, dairy, chocolate
Tx of CAP:
w/ comorbidy : HF, COPD
Beta-lactam: cepodoxime, augmenten, ceftriaxone+cefpodoxime PLUS
macrolide or doxy or resp fluoroquinolone
Pt w/ primary case scabies was probably infected:
a. 1-3d ago
b. 1 wk ago
c. 2wks ago
d. 3-4 wks ago
d: incubation period for scabies is about 3-4 wks after primary infeciton. worse at night
What increases risk of death from pneumonia?
>65yrs, electrolyte or hem disorder (Na<130, absolute neutrophil <1000) other illness.
what temp should water heater be set at for elderly?
a. <110
b,<120
c. <130
d. <140
B: <120
What organism is seen mostly in alocholics w/ pneumonia
Klebseilla. pneumonia
AV nicking is ID in pat w/ what disease?
a. glaucoma
b. cataracts
c. diabetes
d. HTN
D: Hypertension: retinal microvascular changes: early changes, flame hemorrhages or cotton wool indicate severe damage
40y/o w/ multiple, painful reddened nodules on anterior surface of both legs. Concerned. Associated w/ hx of:
a. DVT
b. phlebitis
c. ulcerative colitis
d. alcoholism
c. ulcerative colitis: erythema nodosum: in pretibial locations due to infectious agents, drugs systemic inflammatory disease
What increases Risk of CAP by P. aeruginos:
structual lung, corticosteroid, broad spectrum antibiotic in previous month, malnutrition
Class of medication is NOT used for migraine prophylaxis?
a. beta blockers
b. CCB
c. triptans
d. tricyclic antidepressnats
c. triptans: sumatriptan: abortive agents not prophylaxis: also lithium, SSRI anticovulsants, ACE, ARB
What increase risk of resistant microbes:
repeat exposure to given agent, underdosing, unecessary prolonged tx period
Pt has 2 palpable, tender, left pre-auricular nodes that are 0.5 cm in diameter. What might be found in this pt?
a. sore throat
b. ulceration on tongue
c. conjunctivitis
d. ear infection
c. eye drained partly by pre-auricular lymph nodes
H. influenzae produces beta-lactamase: what antimicrobial is ineffective against this
penicillin
what antimicrobials are useful when beta-lactams are ineffective (atypical pathogens)
macrolides, tetracyclines, respiratory fluoroquinolones
Pt who has been tx for hypothroidism: TSH 4.1. she feels well: managment?
a. cont current meds
b. increase her replacement
c. decrease her replacment
d. repeat TSH in 2-3m
d. non symptomatic pt w/ abnormal TSH should be repeated. include a T4 should be included
What is the best preventative measure to prevent the most fatal form of pneumonia:
obtaining a pneumococcal vaccine
Elderly HTN Pt has osteoporosis. Which anti HTN agen thave secondary effect of improving her osteoporosis?
a. thiazide diuretic
b. CCB
c. ACE-I
d. Beat blocker
a. thiazide diuretics incrase serum Ca by decreasing fluid.
Most common polyneuropathy in elderly:
a. charcot
b. DM
c. urinary incontinence
d. Guillain-Barre syndrome
b: polyneuropathy affects multiple nerves usually periph: burningn, weakness, loss of sensation:
CNS: I, II, III: control or responsible for ?
Olfactory, Optic, Occulomotor (eye movement)
One wk old infant w/ mucopurulent eye discharge bilaterally. What is the etiology?
a. mother has STD
b. Plugged tear duct
c. bacterial conjunctivitis
d. viral conjunctivitis
a. mother has STD: chlamydia sx will appear 1-2wks post delivery. Gonorrhea sx in 2-4days
CNS: IV, V, VI
Trochlear (ear), Trigeminal (temp, pain, tactile), abducens (eye)
CNS: VII, VIII, IX
Facial (Bells palsy), auditory (vestibulocochlear, rinne test), glossopharyngeal (swallowing)
Which pt below should be screened for ostoeporosis?
a. 60 y/o male RA
b. 50 y/o caucasion female
c. 65y/o male otherwise healthy
d. 65y/o post menapausal
a. 60y/o w/ RA: only screen males w/ risk factors, women start at 65y/o
CNS: X, XI, XII
Vagus, Accessory (shoulder shrug), Hypoglossal: protrusion of tongue
Pt w/ c/o sudden decreased visual acuity w/ pupil 4mm fixed. Affected eye is red. What is etiology?
a. stroke
b. brain tumor
c. glaucoma
d. cataract
c. glaucoma: urgent referral to ophthalmology:acute angle glaucoma: also may have n/v
Which increases prostate specific antigen (PSA) insignificantly?
a. digital rectal exam
b. ejaculation
c. prostatitis
d. prostate biopsy
a. digital rectal exam: increase PSA 0.26-0.4 for 48-72 hrs.
What can be a complication of Lyme disease:
bells palsy (need to obtain a titer to verify)
What lab test should be obtained w/ bells palsy:
RPR, veneral disease test, HIV
4y/o child w/ OM w/ effusion:
a. needs antibiotic
b. has viral infection
c. just had acute OM
d. cloudy fluid in middle ear
c. just had acute OM; OME precedes or follows AOM. dont tx w/ antibiotic but f/u for later OM
40y/o w/ lab values of:
HBsAg (-), HBsAb (+), HBcAb (+)

a. had hepatitis
b. never had hepatitis
c. consider immunization
d. Pt has been immunized?
a. had hepatitis:
1. Negative hep B surface antigen (HBsAg)= no hep
2. + hep B surface antibody (HBs Ab)=immune
3. + core antibody (HBcAb)= he has had Hep b
Is Neuroimaging needed w/ bells palsy?
no due to unilateral CN dysfunction on typical of intracranial neoplasm
What is tx of Bells palsy:
may give corticosteroid if w/in 10days of sx
Pt w/ medicare part B. What does that mean?
a. fed gov will pay
b. only covers outpatient services
c. will have co-pay today
d. prescriptions will be partly covered
b. medicate benefit covers out patient services: Prt B pays the examiner: xrya, DME, lab, home health. Charged a monthly fee based on income. There is an initial co-pay
40y/o 5wk hx recurrent HA at night, last 1hr severe behind left eye w/ lacrimation, nasal discharge what is HA dx:
cluster HA
Which med have unfavorable effect on HTN BP?
a. lovastatin
b. ibuprofen
c. fluticasone
d. amoxicillin
b. ibuprofen: Na retention: increase BP, lower extremity edema, increase workload of heart, inhibition of prostaglandin
Agent commonly used to tx pt w/ scabies is permethrin. How often?
a. once
b. one QD x 3d
c. BID for 3d
d. QD x 1 wk
a. once: single whole body from neck down for 8-12hrs
Prophylactic tx for migraines HA:
Propanolol (beta blocker)
Proper technique for removing a tick?
a. tweezers
b. petroleum jelly
c. alcohol
d. hot match
a. tweezers
55y/o woman hx of angina and migraine: best choice of acute HA tx (called abortive migraine therapy)
ibuprofen
Migraine HA typically presents as a _____ Pain
pulsating pain
Which mitral disorder from redundancy of mitral valve's leaflets?
a. acute mitral regurg
b. chronic mitral regurg
c. mitral valve prolapse
d. mitral stenosis
c. mitral valve prolapse: and subsequent degeneration of mitral tissue.
Tension HA typically described as _____ type pain
pressing type pain
Pt was dx today w/ preg. Last preg 3yrs ago. Had protective rubella titer. What should be done about rubella titer today?
a. no need to get one
b. Eval to make sure its protective
c. vaccinate now
d. no need to vaccinate was protective 3 yrs ago.
d. do not need protective 3y ago: protective titer is 1:10 or greater.
Tx options in cluster HA include:
NSAID, oxygen, triptans (imatrex, maxalt)
Pt takes Kava Kava for anxiety: What should you evaluate?
a. LFT
b. bleeding risk
c. thyroid
d. colon polyps
LFT: also tx fibromyalgia, ADHD. Hepatotoxicity reported.
What has the most rapid analgesic onset?
naproxen, liquid ibuprofen, diclofenac, celecoxib (all nsaids)
liquid ibuprofen
Common, early findings in pt w/ chronic aortic regur (AR) is:
a. LVH
b. A-fib
c. pulmonary congestion
d. low systolic BP
a. LVH: enlarges blood regurg from aorta: A-fib is not typcial or usual in AR: pulmonary congestion is seen later. AR b/p is elevated systolic and decrease dystolic
Test of choice to confirm and assess developmental dysplasia of hip (DHH) in 3m old:
a. frog leg x ray
b. plain hip xray
c. US of hip
d. CT of hip
c. US of hip:
What are limitations to Fioricet (butalbital w/ APAP and caffeine?
high rate of rebound HA
Why should neuroleptic meds in migraines be limited to 3x per week?
Their extrapyramidal movement risk:
Most common place for basal cell carcinoma:
a. scalp
b. face
c. anterior shin
d. upper posterior back
b: face
What should the expectation be w/ prophylactic HA tx long term:
approx 50% reduction in number
74y/o dx w/ shingles. NP would prescribe?
a. oral antiviral
b. oral antiviral + oral steroid
c. oral antiviral and topical steroid
d. topical steroid
oral antiviral: w/in 72hrs of sx onset. steroids limited benifit vs risk
48y/o monthly 4d premenstrual migraine, poor response to triptans (serotonin receptor agonist) and analgesic w/ hot flashes what next:
-use continuous monophasic oral contraceptive
-estrogen patch
-triptan prophylaxis
Pt w/ non-fasting glucose of 110 and 116:
a. dx w/ DM
b. impaired fasting glucose
c. get an A1C
d. normal values
d. normal values: for non-fasting: <125 normal values non-fasting
Prophylactic tx for prevention of tension type HA include
desipramine (Norpramin) tricylic antidepressant
Which is always present in COPD?
a. productive cough
b. obstructed airway
c. SOb
d. hypercapnia
Obstructed airwasy: Hypercapnia more common in emphysema (air trapping)
Pt w/ mono: which lab is usually abnormal?
a. lymphcytosis and atypical lymphocytes
b. elevated monocytes
c. decrease WBC
d. elevated liver enzymes
a: lymphocytosis and atypcial lymphocytes: monocytes elevation also occur though not as often as are LFT, WBC
68y/o w/ new HA, bilateral frontal to occipital worse on rising in am and coughing, better mid day. What is causing HA?
increased ICP
Clinical presentation:
Tension Ha
30min-7d w/ >2 of following
-press, nonpulsating
-mild to moderate
-bilateral
- >1 of following then migriane
Nausea, photophob,phonophob
65y/o dx w/ gout: likely that:
a. have elevated uric acid
b. consume too much meat
c. joint like hip or shoulder involved
d. sever inflammation of single jioint
d. single joint: typically great toe: not always have elevated uric: especially w/ acute attack
63y/o male former smoker on simvastatin, rampril, ASA daily. B/P lipids controlled. C/o fatigue and not feeling well. VS normal. What next?
a. CBC and wait a few days
b. ID feeling of depression/hopelessness
c. CBC, metabolic, TSH, UA
d. B12, TSH, CBC, chest xray
c: CBC, metabolic panel, TSH, UA:
clinical presentation : migraine w/o aura:
5 attacks w/:
B. last 4-72hrs
C.two: unilateral, pulsating, mod-severe, activity aggravates
-during HA >1 of following
N/V
photophob and phonophob
Clinical presentation:
Migraine w/ aura
HA w/ or after aura
-focal dysfunction of cerebral cortex or brianstem =>aura sx develop over 4min, =>2sx occur in succession:
-no aura sx last >1hr. then consider alternative dx
Common misconception that pt should avoid MMR if:
a. allergic to eggs
b. allergic to neomycin
c. FHx allergic to MMR
d. taking oral antibiotics
a. allergic to eggs
Clinical presentation:
Cluster HA
occur daily in grps (clusters):
-last wks-months, then dissappear m-yrs
-occur same time of year equinox, 1-8 episode/d. Mostly 1hr into sleep, (alarm clock) HA
-behind one eye w/ steady intense, crescedo pattern 15-3h: Suicide HA w/ lacrimation, conjunctival injection, ptosis, nasal stuffiness
Preg pt w/ pos leukocytes and nitrites in urine. What med?
a. doxy
b. trimethoprim-sulfamethoxazole
c. ciprofloxacin
d. nitrofuratioin
d. nitrofurantoin: good choice tx of UTI in pregnant pt due to coverage: doxy: cat D, TMPS cat C, Cipro: Cat C
25y/o w/ lower abd pain. Etiology of PID?
a. Pos preg test
b. hematuria
c. shift to left
d. elevated sed rate
c: a shift to left
In the absence of neurological exam MRI or CT is usually not indicated?
Yield little additional information compared to cost
Are Migrain w/ or W/o aura more common?
without an aura (effects 80% of migraine) assess for warning of agitation, jitteriness
70y/o diabetci w/ gait difficulty, cognitive disturbance and urinary incontinence. What is diff dx?
a. diabetic neuropathy
b. Normal hydrocephalus
c. parkinsons
d. MS
b. normal pressure hydrocephalus: triad: difficulty, cog distrubance, urinary incontinence:
CT reveals enlarged ventricles
What does SNOOP stand for in HA RED flags
S-systemic sx: fever, weight loss, HIV cancer
N-neuro sx: confusion, LOC
O- onset: sudden, abrupt
O- Old: new onset progressive, >50y/o
P- Previous: FHx, different, change in attack and freq, severity, presentation
Lipid particle w/ greatest atherogenic effect?
a. TC
b. HDL
c. LDL
d. Trig
c: LDL: low HDL and high trig accelerate atherogenesis
Cluster HA are more common in what age
middle age men w/ heavy alcohol and tobacco (suicide HA) over several weeks w/ lacrimation, rhinorrhea
Pharm tx for children w/ HTN should be initiated:
a. those obese
b. Stage I HTN
c. diabetic w/ HTN
d. asymptomatic stage i or ii HTN
c: diabetic w/ HTN:
Which statement is true for NSAIDS for LBP?
a. equally efficacious as APAP for pain
b. more s/E than APAP
c. provide superior relief of sx 1wk
d. should not be used to tx acute LBP
B: s/e are renal impairmetn, ARF, gastritis
What is tx of cluster HA
remove trigger: smoking, alcohol, triptans, NSAID, oxygen
Most common cause fo diarrhea in adults:
a. E. coli
b. salmonella
c. difficle
d. viral GE
D: viral gastroenteritis:
What form of migraine tx has rapid onset but more expensive
injectable: sumatriptona, dihydroergotamine: 15-30min. best if GI upset
Most common cause fo diarrhea in adults:
a. E. coli
b. salmonella
c. difficle
d. viral GE
D: viral gastroenteritis:
What are triptans and why are they used in HA (migraine): Preventative therapy used daily: Imitrex
selective serotonin receptor agonist: increase uptake of serotonin which vasoconstrics blood vessels decrease inflammation. (CONTRindicated in Prinzmetal angina or CAD or pregnant, or recent use of ergots)
What are ergotamines and why are they used in HA (migraine but NOT tenstion)
vasoconstrictor effects: avoid in hx of CAD
Pt received antibiotic for 10 d for pneumonia. Resp sx have resolved but now has watery diarrhea, abd cramp, lower grade fever. What next?
a. give anti diarrheal agent
b. force fluids
c. order stool specimen
d. wait 24hrs for resolution of sx
c. order stool specimen: Hx of antibiotic = C. difficile. If bacterial GE then get stool sample
NSAIDS are useful for what type of HA
tension and migrain: inhibit prostaglanding and leukotriene synthesis (use first sx of Ha)
3 most common causes fo bacterial diarrha in US are salmonella, campylobacter and:
a. e. coli
b. enterovirus
c. yersinia
d. shigella
d. shigella:
Which has best relief w/ HA: NSAID or APAP/ ASA
NSAID due to improved analgesic effect
20y/o reports nocturnal HA of recent onset. What is NOT part of diff dx in patient?
a. migraine HA
b. Brain tumor
c. hydrocephalus
d. cluster HA
c. Mirgraine HA begin early morning, awaken pt from sleep. Cluster HA are very likely in age and gender. brain tumor always considered. Hydrocephalus not specific to night time
Pt w/ allergic rhinitis has sinus infection. Takes fexofenadine daily.What should be part of med regimen w/ an antibiotic?
a. stop fexofenadine and add decongestant
b. add decongestant and nasal steroid
c. cont fexo and antbiotic only
d. cont fexo and add a decongestant
d. cont his fexofenading: adding decongestant promotes drainage, speed resolution of sinus. nasal can be added but only if poor control of allergies
Fioricet w/ caffeine, butalbital and APAP: use and type of HA
enhances neurotransmitter action, dependency risk and rebound
Midrin (isomethepetene, APAP, dichloralphenzone: used in and caution
migraine and tension HA: Contraindicated if vasoconstriction concern
18y/o female pt w/ Fe IDA. Anemia has occurred in past 3-4m. what might be expected?
a. incrased RDW
b. decreased rDW
c. elevated serum ferritin
d. decreased TIBC (total iron binding capacity)
a. increased RDW: RDW is RBC distribution width. Recent onset iron deficiency anemia. Variation in size of RBC demonstrated by increased RDW. Serum ferritin measure of iron store. TIBC is always increased in pt w/ IDA.
Study listed below is considered experimental study?
a. case series
b. cross-sectional study
c. cohort study
d. meta-analysis
d. meta-analysis: observation studies are studies where subj r observed. no intervention takes place.
Excedrin Migraine: ASA, APAP, caffeine: OTC: type HA
migraine and tension: excessive use may causes rebound
Initial med to tx pt w/ initial episode of depression?
a. tricyclic
b. MAOI
c. SSRI
d. no preferred
c. SSRI: ?? no clear choice on selection for efficacy, however, SSRI are usually first choice due to lower side effects.
Neuroleptics: adjuct therapy to what type HA
migraine: control N/V, sedating
What are some examples of neuroleptics used in migraine tx:
Compazine, phenergan: used >3xwk increase risk of extrapyramidal effects
Preg pt first trimester found to have chlamydia. How should this be managed?
a. tx w/ azithromycin
b. tx w/ ceftriaxone by injection
c. doxycycline
d. do not tx during 1st trimester
a. azithromycine: 1Gm dose, screen for STD now and prior to delivery due to reinfection.
What are the risks of Opiod use?
dependency (habit), sedating use sparingly, respiratory distress if OD
Serotonin syndrome from taking SSRI and :
a. dextromethorphan
b. loratadine
c. pravastatin
d. niacin
a. SSRI and dextromethorphan (triptan): sx of hyperreflexia, clonus, rigid lower extremities, tachy, hyperthermia, HTN, vomiting, disorientation, delirium
What receptor do most HA medication work on?
5HT2 receptor: 1-2m use is required to be effective prophylactic
80 y/o w/ BP of 176/80. tx?
a. thiazide diuretic
b. ACE-I
c. CCB
d. ARB
Pt w/ isolated systolic hypertension (ISH). increase cardiac and cerebral events. Tx w/ long acting CCB (amlodipine, felodipine)
Pt w/ diabetes right lwoer leg edematous, erythematous tender to touch over anterior shin. no evidence of pus leg is warm: dx?
a. DVT
b. buergers disease
c. cellulitis
d. venous disease
c. cellulitis:
Buergers = inflammation of med size arteries and no shin pain
DVT: rare anterior pain
What are some HA inducing medications:
estrogen, progesterone, vasodilators
Sexually active male pt w/ epidiymitis: likely finding?
a. abnormal urinalysis
b. dysuria
c. rectn hx heavy exercise
d. scrotal edema
c. recent hx of heavy lifting: no scrotal edema, (hydrocele)
HA due to ICP presents w/ c/o
worst on awaking but decreases throughout day.
Pt w/ glucose 302 w/ sx of diabetes: Tx?
a. return tomorrow to recheck glucose
b. start metformin
c. start insulin
d. start metformin and pioglitazone
C: start insulin: glucose >200 sx is toxic. oral agents have little effect on his glucose. return tomorrow for recheck of glucose
Tension Ha present w/ c/o
worsen as the day progresses
Swimmers ear is dx in pt w/ tragal tenderness. what other sx present?
a. OM
b. Hearing loss
c. otic itching
d. fever
c. otic itching: tx w/ topical agent and keep dry
18y/o c/o HA fever, + kernig and Brudzinski signs: Dx
meningitis
19y/o dx meningococcal meningitis: who should receive prophylactic tx
those w/ household type exposure: >4hr/wk exposure
Pt w/ heavy menses. What lab value reflects IDA?
a. elevated TIBC
b. decreased TIBC
c. norm serum iron
d. decrased RDW
a. elevated TIBC: reduced RBC count and decreased H&H. RDW would increase.
Bacterial meningitis w/ show ____ on CSF
glucose at 30% of serum level
Initial pharmacologic approach to pt dx w/ primary dysmenorrhea could be:
a. APAP
b. NSAID at time sx begin or menses
c. NSAID prior to onset of menses
d. combination APA and NSAID
NSAID at time sx begine or onset of menses
Which is pt w/ acute cholecystitis?
a. pt rolls from side to side on exam table
b. pt is ill appearing and febrile
c. elderly pt is more likely to exhibit murphys sign
d. most are asymptomatic until stone blocks bile duct
b: pt ill appearing and febrile: pt w/ acute cholecystitis usually complains of abd pain in URQ:
Viral or aseptic meningitis expect to find CSF___
predominance of lymphocytes
NP initiates insulin in pt taking oral diabetic med. How much long acting insulin should be initiated in pt who weighs 100kg?
a. 5u
b. 10u
c. 15u
d. 20u
d: 20u: 100kg x 0.2=20U.
Then 3d AM fasting measurements so AM fasting is at 100-120mg: adjust dose as needed to meet goal
Describe Kernig sx
pt lying supine - hip flexed 90 degree; knee extension = resistance or pain to lower back or posterior thigh
Pt w/ leukocytosis:
a. has bacterial infeciton
b. has viral infection
c. infection unknown origin
d. does not have infection
c: infection unknown origin:
Leukocytosis has predominance of WBC in blood. May elevate to viral or bacterial.
Papilledema is what:
optic disk bulging caused by elevated ICP bilateral
Who should the NP obtain a CSF on as part of eval for Fever
younger child w/ altered neurologic findings
Pt found to have eosinophilia. An expected finding is:
a. asthma exacerbation
b. bronchits
c. hepatitis
d. osteoporosis
a: asthma exacerbation: or parasitic infections.
What do you expect to find in CSF (WBC) of meningitis:
Pleocytosis: WBC >5cells/mm whether: bacterial, viral, tubercular, fungal or protozoan
3y/o tx for URI but drainage from right nostril persist. What should u suspect?
a. allergic rhinitis
b. presence of foreign body
c. unresolved URI
d. dental caries
b. foreign body:
1. continued drainage despite tx
2. drainage is unilateral
What do you expect to find regarding glucose and protein of CSF in bacterial meningitis
decrease normal glucose (<60%), elevated protein levels
4y/o presents w/ fever, rhinnorrhea, paroxysmal, high pitched whooping cough. This is?
a. bronchiolitis
b. croup
c. pertussis
d. epiglottitis
c. pertussis: is whooping cough:
3stages: cararrhal phase, paroxysmal and convalescence:
Most common sx associated w/ gastroesophageal reflux disease are heartburn and :
a. cough
b. reguritation and dysphagia
c. cough and hoarseness
d. belching and sore throat
3 most common associated sx of GERD are heartburn, post prandial, regurgitation and dysphagia
What do you expect to find in glucose and protein of CSF in viral meningitis
normal glucose, normal protein but +lymphocytosis
Niacin is known to:
a. increase fasting glucose
b. produce HTN
c. decrease trig
d. decrease HDL
a: decrease glucose tolerance: use w/ caution in pt w/ Impaired fasting glucose. Used to increase HDL
What diagnostic should be performed prior to Lumbar puncture on suspected meningitis
MRI or CT scan
Pt dx w/ mononucleosis. Which statement is correct?
a. Likely adolescent male
b. spelnomegaly more likely than not
c. cannot be co-infected w/ strep
d. cervical lymphadenopathy prominent
d. lymphadenopathy, fever, fatigue, pharngitis (FFFL): mono is common in adolescents and college: it is possible to co-infect: Avoid tx w/ PNC due to rash.
What are common pathogens in bacterial meningitis adult:
S. pneumonia, N. meningitis, staph and H.influenzae
Vit B-12?
a. is easily absorbed through GI
b. deficiencies are seen in elderly pt only
c. low level can result in elevated lipids
d. inadequate amounts can produce cognitive changes
d: B12 is absorbed through GI tract from foods, BUT when supplements taken they are NOT absorbed well in GI. Usually life long once deficiency noted.
Clinical presentation of bacterial meningitis:
classic triad: fever, HA, nuchal rigidity
What is brudzinski sign
Passive neck flexion in supine => flexion of knees and hips (meningitis)
Pt w. hyperlipidemia:
a. a statin daily
b. TSH levels
c. second measurement to confirm dx
stress test
b: TSH: elevated TSH may causes eleveated lipids: dont tx lipids until TSH confirmed and decreased to at least 10; then tx lipids
What does absence of venous pulsation during eye exam indicated?
increased ICP
Adolescent female normal menses for 2 yrs, but no menses for last 3m. Dx w/ polycystic ovarian syndrome. What else expected?
a. obesity
b. elevated insulin
c. +HCG
d. HTN
B: PCOS is a systemic disease of multiple cysts about the ovaries. Overwieght is common. elevated insulin is common in PCOS
How many hr of exposure increase risk of passing meningitis:
> 4 hours, wk prior to sx
26y/o female w/ flank pain that waxes and wanes. Urin indicates presence of:
a. blood
b. nitrites
c. leukocytes
d. Ca
a. sx of pt w/ kidney stones: Blood is always expected in urine. Nitrites and leukcytes ore indicative of UTI.
What is antimicrobial options in bacterial meningitis
rifampin (antituberculin), ciprofloxacin, ceftriaxone
What is the first sign that a male child is reaching sexual maturation?
a. increase testicle size
b. enlargement of scotum
c. increase length of penis
d. scrotal and penile changes
a. increase testicular size
Pt w/ suspected plantar fasciitis. What is best way to examine?
a. great toe dorsiflexed
b. foot in neutral position
c. patient stands
d. ankel at 90 degreee
a. when great toe is dorsiflexed: plantar fascia is easy to palpate due to tightening.
34y/o dx w/ MS what is the typical pattern
variable exacerbations and remissions
Young athlete w/ depression of longitudinal arch of both feet. C/o heel pain bilaterally. Normal foot exam and cont activities. What is recomendation for foot pain?
a. xray foot first
b. heel support in shoes
c. NSAIDs initially
d. rigid orthotics
b. heel support: consider flat foot, tx w/ well support heel counter. NSAIDs wont correct underlying, orthotics may increase pain.
Tx options in MS to attenuate disease progression:
interferon B-1B
40y/o has aortic stenosis wants to know what sx indicate worsening?
a. palpitations and weakness
b. ventricular arrhythmias
c. shortness of breath and syncope
d. fatigue and exercise intolerance
c. shortness of breath and syncope:
3 most common sx of AS is angina, syncope, and CHF (dyspnea)
What is consistent presentation of parkinson
tremor at rest and bradykinesia
What are tx options (pharm) w/ parkinsons
levodopa, ropinirole, pramipexole
Pt w/ mono has pharyngitis, fever and lymphaadenopathy. Sx started 3 d ago:
a. he will have pos mono
b. he normal CBC
c. could have neg Mono
d. could have pos mono and normal CBC
c. cough have neg mono:
Monospot detects presence fo heterophile antibodies in mon. If mono spot is too early it will be neg. If pt sx persist repeat mono. Lymphocytosis is normal in mono so pt will not have a normal CBC
Pallidotomy is helpful in managment of parkinsion disease associated w/ refactory ______
dyskinesia
pt w/ pneumonia reports rust colored sputum. What pathogen?
a. mycoplasma pneu
b. chlamydophila pneu
c. staph aureus
d. strept pneu
d. strept pneu (pneumococcal pneu)
mycoplasma and chlamydophilia has scant or watery sputum
Thick discolored is bacterial
6y/o tx for CAP taking azithromycin for 72hrs. Temp is 102 to 101, what should be done?
a. cont same dose and monitor
b. increase dose to high dose azithro
c. change to PNC
d. viral, stop antibiotic
c. change to PNC: CAP should improve in 24-48hr: consider high dose amox due to increase incidence of resistant stept
What are common sx of MS:
numbness of limb, monocular visual loss, dipolia, vertigo, facial weakness o rnumbness, sphincter disturbance, ataxia, nystagmus
How is MS classified, what are the stages?
1. relapsing remitting MS: no neuro effects after remission
2. chronic progressive: episodes do not fully recover and accumulative defest
Head circumference shed until a should be measured until what age:
a. 12m
b. 18m
c. 24m
d. 36m
d. 36m: above the ears
MS typical progression:
relapsing-remitting for years later develop chronic progressive
Niacin can:
a. decrease TC and TRig
b. decrease Glucose and LDL
c. cause flushing and HTN
d. increase liver enzymes
d: increase liver enzymes:
it increases glucose
does not cause HTN, hypotension is common
Which pt is most likely to have mitral valve prolapse?
a. adolescent male w/ no cardiac hx
b. 25y/o male w/ exercise intolerance
c. 30y/o female w/ no cardiac hx
d. 65y/o male w/ SOB
c: 30y/o female w/ no cardiac hx: most common in women 14-30: common sx: arrhythmias, and chest pain. most are asymptomatic
Why is MS difficulty to dx:
sx of recurrent fatigue, muscle weakness and other nonspecific sx occur w/ mult illness
New born w/ hyperbilirubinemia: When would bilirubin be expected to peak?
a. 1-2d
b. 3-4d
c. 5-7d
d. 7-10d
b: 3-4d: premi: 5-7d
What are then name of maintenace therapy for MS: interferon B-1b
Betaseron: reduces exacerbations
Grp A strept pharyngitis:
a. single sx
b. also has abdominal pain
c. no exudative sx
d. has inflammed uvula
b. can be accompained by abd pain:abrupt onset: sore throat, fever, GI: n/v: w/o tx resolves in 3-5d
What immunosuppresive therapy is used in MS
methotrexate or mitoxantrone
Most common pathogen in pt w/ pyelonephritis:
a. pseudomonas
b. steptococcus
c. E. coli
d. klebsiella
E. coli: as a pt age E. coli decrease and Klebsiella increases
What are the six cardinal signs of Parkinson:
tremor at rest, rigidity, bradykinesia, flexed posture, loss of postural reflexes, mask like facies (tremor at rest or bradykinesia must be present)
What is typical in Parkinson gait:
rapid small steps, turning takes several steps move forward/back
45y/o w/ following:
HBsAg (+), HBsAb (-), HBcAb (-)
a. has hepatitis
b. had hepatitis
c. consider immunization
d. results indeterminate
A: has hep:
+ hep B surface antigen (HBsAg) = has Hep
2. early in desease due to no core (HBcAb)
3. HBsAb should be neg due to HBsAg being positive (+ after immunization)
What is the tx of choice in parkinsons and why
ropinirole (Requip) and pramipexole (Mirapex) dopamine agonist
table for determination fo max BP values fro children are based on:
a. height %, BMI, gender
b. gender age
c. height %, gender age
d. BMI and gender
c. height %, gender age:
63y/o former smoker, takes simvastatin, ramipril and ASA: BP and lipids controlled, c/o fatigue and not feeling well: VS normal, hep panel neg: What is most likely cause for his elevated liver enzymes?
a. generic version of simvastatin
b. alcoholic in denial
c. daily grapefruit for 10 days
d. rare liver toxicity from usual dose of simvastatin
c. daily grapefruit: inhibits cytochrom P450. Statins and CCB react w/ grapefruit
What develops after taking levodopa for 5-10 yrs for parkinson
dyskinesia (tics of hands, face)
Female pt present w/ tenderness at Mcburney point. Appendicitis is considered. What lab test woud LEAST helpful to Exclude appendicitis?
a. CBC w/ elevated WBC
b. UA w/ leukocytes
c. Pos serum preg
d. Pos pelvic culture
a: CBC w/ elevated WBC: simply indicates and infection
2. UA to r/o UTI
3. Serum preg for ectopic
4. pelvic culture for PID
What is used to reduce dyskinesia
Symmetrel: may only be used 1yr.
Why is pallidotomy used:
surgical therapy management of dykinesia in parkinsons: removal of gladius pallidum
Pt w/ hep B probably has a predominace of :
a. leukocytes
b. lymphocytes
c. neutrophils
d. eosinophils
b. lymphocytes: increase w/ viral infections but total WBC will be decreased.
Elderly pt w/ urinary frquency and UTI. What drug could produce an arrhythmia?
a. doxy
b. amoxicillin
c. ciporfloxacin
d. macrodantin
c. ciproflaxacin: (quinolone): prolong QT interval.
Describe absence seizure (petit mal)
blank staring 3-50 sec w/ impaired LOC
Pt w/ monoucleosis most likely:
a. lymphcytosis
b. eosinophilia
c. leukocytosis
d. monocytosis
a. lymphocytosis: viral
eosinophil = parasitic or allergic
leukocytosis no specific for mono
monocytes rise but not specific for mono
Describe simple partial seizure?
awake state w/ abnormal motor lasting seconds
Describe tonic-clonic (grand mal)
rigid extension of arms and legs then sudden jerking w/ LOC
Which form of BC presents highest risk of STD exposure?
a. intrauterine device
b. progestin only pill
c. diaphragm
d. barrier protection
a: intrauterine device
Pt w/ pos Kernig and brudzinski signs. Dx?
a. hep
b. encephalitis
c. menigitis
d. pneumonitis
c: meningitis:
Kernig: neck pain and flexion w/ leg extension
Brudzinski: passively flex neck --> flexion of legs
Describe myoclonic seizure
brief, jerking contraction of arms legs or trunk
Atopic dermatitis exacerbation are tx w/:
a. emollients
b. topicla steroids
c. antihistamines
d. antibiotics
b. topical steroids: eczema: keep well lubricated w/ emollients but for exacerbation --> topical steroids (lowest potency)
Tx for seizure include:
carbamazepine (tegratol) phenytoin (dilantin), gabapentin (neurotin), clonazepam, valproic acid (AED)
When taking phenytoin w/ ____ may exhibit toxicity
theophylline
Pt presents w/ severe toothache. Sensitivity to hot and cold w/ visible pus around painful areas:
a. pulpitis
b. caries
c. gingivitis
d. perodontitis
a. Pulpitis:
Caries and gingivitis have no pus.
What is the risk of giving phenytoin w/ other high protein bound properties:
may result in displacement from protein binding site => increased free phenytoin => toxicity
20y/o B-ball player lands has possible sprain yesterday. c/o ankle and foot pain but limps: management
a. RICE
b. non-weight bearing until fx ruled out
c. short leg splint
d. NSAIDs rest partial non-weight bearing
b. non-weight bearing till fx r/o
Which is true of tension HA (THA) but not cluster HA (CHA):
a. CHA alwyas bilateral
b. THA always bilateral
c. CHA always cause nausea
d. THA cause photophobia
b: Tension headache is always bilateral w/ nausea and photosensitivity
cluster are always unilateral w/ red teary eye nasal congestion
What are risk factors for TIA
Afib, CAD, oral contraceptive
Private NP clinci, presents w/ trichomonas. State law requires reporting of STD Pt request not o report due to husband working at health dept: what do you do?
a. dont report
b. tell pt you wont but do it
c. report it
d. report but w/ little details
C: report it: names or ID are not part of reporting.
Delirium has acute or insidious onset?
acute: usually w/ change to medication w/ anticholinergic
Women who use diaphragm for contraception have increased incidence of :
a. STD
b. preg
c. UTI
d. PID
c: UTI:
Pneumonic for delirium: DELIRIUMS
D: drugs
E: emotion
L: low oxygen
I:infection
R: retention urine or feces
Ictal or postictal state
U- Undernurished: b12, folate, dehydration
M: metabolic (DM, thyroid
S: subdural hematoma
What is the tx of demintia/alzhiemers
Cholinesterase inhibitor (Aricept)
Depression dx on clinical presentation. What time frame distinguishes depressed mood from clincial depression?
a. 1wk
b. 2wk
c.3wk
d. 4wk
b: 2wks:
Pt w/ cough variant asthma:
a. all wheeze
b. all cough
c. cough and wheeze
d. dyspnea
b. all cough
Define Primary HA
not associated w/ other disease, Migraine, tension type
Pt has fatigue, weight loss, TSH 0.5. What is likely dx:
a. hypothyroid
b. hyperthyroid
c. subclinical hypothy
d. more test r needed
b. hyperthyroid:
Define Secondary HA
Associated w/ or caused by other conditions, does not resolve until cause resolved: ICP, brain tumor, bleed, inflammation
Female should be told to take OCP at bedtime if:
a .weight gain
b. HA
c. nausea
d. spotting
c. nausea:
When does the evidence suggest to obtain Neuroimaging w/ nonacute HA
Hx: dizzy, numbness, HA awakens from sleep, worse w/ valsalva, accelerating, new onset
What might be suggested if patients says "worst HA of my life"
Consider hemmorhage.
15y/o female never menstruated. What is most important for NP to assess?
a. stature
b. tanner stage
c. anemia
d. FH of amenrrhea
b. tanner stage: breast and pubic hair signify pubertal changes of maturation.
What are some lifestyle triggers for migrianes
Menses, ovulation, preg, BC, illness, intense activity, sleep to much to little, missing meal, bright light, odors, weather, altitude ,meds, stress
which drug is NOT associated w/ weight gain?
a. insulin
b. pioglitazone
c. citalopram
d. metoprolol
d. metoprolol: BB
most diabetic med cause weight gain
What dieatary triggers infleuence migraine
ripened cheese, liver, herring, MSG, chocolate, alsohol, caffeine ect
Primary therapeutic intervention for hives:
a. steroids
b. anti-histamines
c. CCB
d. topical steroid cream
antihistamine
Kegel exercises helpful for pt w/ what type of incontinence?
a. stress
b. urge
c. mixed
d. overlfow
a: kegel for stress incontence: 3 sets fo 8-12 slow 3-4xwkly
What strategy is used to slow decline of the Alzheimer type dementia patient?
Vit E 10000 IU Bid or selegiline 5mg BID
Pt w/ acute drooping right eye an drooping right upper lip. right side of her face is numb. Otherwise healthy. How do you manage?
a. steroids plus an antiviral agent
b. Immediate referral to ER
c. antihistamines and steroid
d. steroids only
d. steroids only: bells palsy. prednison 60-80mg/d tapered over a wk w/in 72hrs of onset
AAN: Alz dementia: strategy:
mild to mod, use of cholinesterase inhibit mainstay of tx: what r they
Donepezil (aricept), rivastigmine (Exelon), time limited benefit 6-12m. Increase acetylcholine in brain. Aricept only tx approved for all stages of alzheimers.
What recommendation for assessment of prostate gland in man who is 40y/o? He should have:
a. screening starting at 50y/o
b. PSA now
c. PSA and digital rectal
d. digital rectal exam only
d. digital rectal exam only:
50: DRE and PSA
Risk: Fhx or race = screen 5yrs earlier
What are diff dx of dementia in older adults w/ similar sx:
depression, pain, infection
Pt dx w/ mild chronic CHF. Which drug manages sx and improve outcome?
a. verapamil
b. digoxin
c. furosemide
d. monopril
d. monpril: ACE-I: reduce mortality and morbidity in CHF:
CCB are contraindicated
Lasix and dig improve sx but not long term outcomes
Physical finding in COPD include
decrease tactile fremitus, wheeze, prolonged expiratory phase of forced exhalation, low diaphram, increased AP diameter, reduced forced expiratory volume at 1 sec, reduction in Sats.
Ankle inversion is common complaint from pt w/:
a. medial ankle sprain
b. lateral ankle sprain
c. severely torn ligament
d. fx of medial malleolous
b. lateral ankle sprain:
NAEPP-EPR-3 Goals of asthma care
1. minimal/no chronic sx of cough/wheeze
2. few/no ER visit/hospitalization
3. Minimize air remodeling(inflame)
4. Minimal/no prn short acting beta 2 agonist (<2d/wk w/ beta2 except for sprots
5. no limitation to activity
65y/o pt w/ firm, non-tender, symmetrical enlarge prostate gland; PSA 3.9ng/ml:
a. prostate cancer
b. BPH
c. prostate infection
d. perfectly normal prostate gland
b: BPH:
Infection would have higher PSA
What is the most common reason for protracted asthma exacerbation
viral URI
Pt w/ asthma w/ acute episode of wheezing, cough, and fever. Wheeze right upper lobe. cough non-productive. Which sx is not relate to asthma?
a. wheeze and fever
b. cough and wheeze
c. fever cough
d. cough fever
a. wheeze and fever: consider pneumonia if only in right upper lobe and fever
Long term O2 therapy in COPD:
Goal
- increase baseline PaO2 at rest to >60mm/hg or SaO2 >90% or both
- Indication to intiate long term: PaO2 <55mm or SaO2 <88% w/ or w/o hypercapnia, HF, cor pulmonale, polycythemia
60y/o female hx of recent LBP. Gait is antalgic and loss of bladder function since LBP. Tx?
a. physical therapy
b. ER
c. Refer to neurologist
d. keep no-weight bearing until xrays
b: refer to ER: sx of cauda equina syndrome.
What is a risk specific to females of developing DM?
Hx of gestational diabetes
Pt w/ small vesicles on lateral edges of fingers and intense itching. Exam reveals small vesicles on palmar surface of hand. What is this called?
a. seborrheic dermatitis
b. dyshidrotic dermatitis
c. herpes zoster
d. varicella zoster
b. dyshidrotic dermatitis: is a condition in which small, usually itchy blisters develop on the hands and feet. Symptoms: Small fluid-filled blisters called vesicles appear on the fingers, hands, and feet.
Dx of DM2 can be made by:
glucose of 126 and 136:, glucose >200mg and confirmed or glucose tolerance w/ 2 abnormals
Screening for DM2 should be while:
fasting
Pt w/ migraine HA and HTN should receive which med w/ caution?
a. BB
b. triptans
c. pain med
d. ACE-I
b. triptans: produce vasoconstrictions: increase HTN.
Undiagnosed DM may present as what in females
vaginal candidiasis (elevated glucose feed yeast)
Female 45y/o urinary frequency. Having to go right now. UA is normal. Differential?
a. diabetes
b. lupus
c. stress incontinence
d. asymptomatic bacteriuria
a. diabetes: may consider urge incontence or vaginitis. review meds for diurectics or herbal
What is most important screen for diabetic nephropathy
Microalbumin: earliest indicate of kidney damage. if + reassess 3-6m
Screen in all DM >12y/o
NP not increase dosage of antihypertensive even though pt BP is still 140/90. Might be described as:
a. clinical inertia
b. malpractice
c. resistant HTN
d. lackadaisical attitude
a. clinical inertia: providers who fail to intensify therapy despite pat not reaching goal
What is the earliest glycemic abnormality?
postprandial glucose elevation
NP fundoscopic exam. ID small dull yellowish-whit coloration in retina?
a. cotton wool spots
b. microaneurysm
c. hemorrhages
d. exudates
a. cotton wool spots: impaired blood flow to retina, diabetes and HTN.
What is the typical presentation of DM2?
Insidious onset w/ weight gain. found on screening for fasting glucose
DM1 typical acute onset
ADA: what is tx of DM2 after oral meds have failed?
intermediate or long acting insulin at bedtime or morning 1xd 10U or0.2/kg. Cont oral unless sulfon or meglit (d/c)
Elevated glucose evening meal indicates what in a DM
not enough AM intermediate insulin, increase dose to 2-3U at a time, check sugars 3 d after change. Cont increase 2-3 until at goal
sx that may present as DM2 inlcude:
fatigue, athletes foot (glucose), infected mosquito bites
Acanthosis nigricans due to:
obese insulin resistance
What should target HR be in new DM
120s to 70s, the lower the better (w/in reason)
When do you screen a new DM2 for renal nephropathy
at diagnosis
How soon can you determine anti-proteinuric effect of ACE-I
6-8wks
What is the next lab if a pos albumin screen?
spot albumin w/ creatinine ratio
what is the definition of renal neropathy?
>300mg/d of albuminauria on 2 occasion seperated by 3-6m
What are the target lipids for DM according to ADA
HDL >50
LDL <100
Trig <150
what increases A1C
glucose and alcohol
What is the relationship w/ triglycerides and A1C:
Triglycerides w/ increase w/ A1C
How does hyperthyroidism affect blood pressure?
increase systolic and diastolic, HR is typically >100
What are some endocrine causes of secondary HTN?
pheochromocytoma, Cushings, neuroblastoma,
What is the normal value of TSH?
5.0
What lab abnormality is common w/ hypothyroidism? not involving the thyroid or pituitary
hypercholesterolema
What is the most sensitive test for majority of hypthyroidism?
TSH only
45y/o female TSH 13 then 1m later 15 what is the dx:
hypothyroidism
Hx of tx for hyperthyroidism will now likely have?
hypothyroidism
Serum free T4 falls TSH will?
TSH will rise
Hypercholesterolemia is common when TSH is >than ____
10 mU/L: dont tx hyperlipidemia until TSH <10
What are common lab findings in hypothyroidism not associated w/ thyroid or pituitary?
hyponatremia, hyperprolactinemia, hyperhomocysteinemia, anemia, elevated creatinine
What are medication and disorders that can increase TSH
metoclopramide (reglan), amiodarone, adrenal insufficiency, pituitary, generalized thyroid hormone resistance
what are common sx of hypothyroidism?
fatigue, weight gain, dry skin, hair nails that break easily, cold intolerance, constipation, menstrual irregularities
Tx of hyperthyroid has an inverse result of?
destroying the gland ability to produce thyroid hormone T3 and T4
What may happen to TSH if synthroid is substitued by a generic med?
TSH will vary due to the different bioavailablities of generic meds
How do you determine amount of T4 to replace (synthroid) in a patient?
replacement based on weight in Kg and multiply by 1.6 for 1 day.
What do you expect to FSH to do in a menopausal women w/ hot flashes and no period for 12m
increase (follicle stimulating hormone) best diagnostic is PE: bleed change, hot flash, sleep disturbance, GU sx
How long before PAP smear should women not have sex, douch, or use tampon
48hrs prior to PAP
60y/o w/ small amount vag bleed, postmenopausal x 2 yrs dx would be?
atrophic vaginal mucosa (endometrial carcinoma is a concern but rare)
28y/o w/ primary dysmenorrhea OTC motrin, naproxen what next tx?
oral contraceptives
Dx of osteoporosis is made when what diagnostic test?
BMD bone mineral density 2.5 more from standard or T-score of -2.5 or less
What is the usual age recommendation for HPV test?
21yrs or 3years after first sexual intercourse
Primary risk factor for breast cancer is?
age
A localized tumor in prostate gland will have what sx?
none: but will be indurated on exam
Hematuria is uncommon clinical manifestation in what early male cancer?
prostate cancer
30y/o w/ lump to breast during menses what is the next step?
advise to return 3-20 days after menstation to reasses, if any concern then mammogram and US
DRE (digital rectal exam): it is not acceptable to perform while: standing, kneeling, lying on side, in lithotomy position
kneeling: best way is supine and legs in stirrups
A radical prostatectomy 6 m ago now urinary incontinence what is going on?
a common complication, subsides in 2yrs and/or develop ED
What med should be avoided in benign prostatic hypertrophy (BPH)?
nasal decongestant: may increase urge to urinate
What age should digital rectal exam be perfromed for prostate cancer, what age should PSA and dRE
40 for DRE and 50 for both
When should PSA and DRE be perfromed on blacks?
before the age of 50yrs, five yrs prior to other races
What is the most common cause of epididymitis in <35y/o.
Chlamydia trachomatois, in older men >35 UTI is most common
Why are truck drivers predisposed to noninfectious epididymitis:
reflux of urine into epidimyis from ejaculatory ducts and vas
Inguinal hernia is hernation of what
bowel or omentum into scrotum
How does an inguinal hernia present?
scrotal pain and a scrotal mass or scrotal swell (abd pain) bowel sounds in scrotum (w/ a stethascope??)
What is Hesselbach triangle?
inguinal ligament, rectus muscle and epigastric vessel: Inguinal hernia
patient dx w/ cluster HA should eliminate what?
triggers like nicotine and alcohol
Audible carotid bruits indicate?
Atherosclerosis: increase probability of death from CVA or CAD
Mini mental status exam assess?
mild alzheimers
Differential dx of suspected alzheimers also includes?
tumor, cerebral hemmorage, cerebral infarct
what is included in the mini mental exam?
orientation, short-term memory-retention, short-term recall, language, attention (does NOT dx alzheimers)
How long after initiating acetylcholinesterase inhibitor should you eval for efficacy
6-12m: assess caregiver feedback, repeat mental status, ADL, S/E cost
What increases the risk of and elder being abused?
decrease cognative due to caregiver strain, stress depression
What does the snell chart test?
distant vision and CNII
Giant cell arteritis: temporal arteritis is best dx by?
temporal artery biopsy
What is the typical complaint of temporal arteritis:
new onset HA, abrupt visual change, jaw claudication, fever or anemia elevated sed rate 72y/o
Where is carpal tunnel usually felt on the fingers?
thumb, index finger middle finger and radial side of ring finger
What structures are directly affected by carpal tunnel?
Medial nerve: inflammation of wrist tendeons, transverse carpal ligament
What are 4 prominent features of Parkinson?
bradykinesia, muscular rigitdity, resting tremor, postural instability
What is anosmia?
inability to smell, CN 1 olfactory nerve (peppermint or coffee)
What CN is responsible for hearing
CN 8
What CN is responsible for eye movement
III, IV, VI
What CN is responsible for facial sensation?
CN V (light touch test)
What may be an indicator of hemorrhagic stroke?
headache w/ stroke
What diagnostics does a pt w/ new onset TIA
CT and/or MRI, ECG, CBC, PTT< lytes, creatinine, glucose, lipids transcranial doppler US
What should you do w/ a new onset TIA?
immediate ER referal
Why is ASA used as an antiplatelet therapy?
ASA inhibits enzyme cyclooxygenase adn reduces thromboxane A2 production
Define Secondary prevention?
intervention to help prevent second occurrence of deleterious event. ex: ASA after a stroke
What is the criteria for migraine? (5 criteria)
1. lasts 4-72hrs
2. HA has 2 of following: unilateral
3. pulsating mod to severe pain aggravated routine activity
4. 5 attacks which fulfill these criteria
5. no underlying illness
6. photophobia, phono
Which are most likely triggered by food: migraine or tension
migraine: sx nausea, worse w/ activity
Does Bell palsy present w/ pain.
NO: sx of sagging eyebrow, impaired blink, mouth drawn up
How long after a rubella should a pt avoid pregnancy
1 month (though no documented injury of offspring) safe when breastfeeding
What immunizations can be given in 1st trimester?
influenza, tetanus, diptheria
When should varicella be given in pregnancy?
Never, no live viruses should be given during pregnancy
What are 3 classic sx of ectopic pregnancy?
amenorrhea, vag bleed, abdominal pain
Due dates are used to:
Assess fetal growth provide accurate data for screen test if LMP cant be determined do an US to determine fetal age.
What does pregnancy test assess the prescence of...
beta hCG: best 1st void in am or anytime if serum
Tx of asymptomatic bacteriuria in pregnancy?
Tx w/: nitrofurantoin (Macrobid): prevents pyelonephritis, Ciprofloxacin (quinolone should be avoided in preg), Amoxicillin is poor coverage of E.coli.
Should all pregnant pt be screened for hypothyroidism?
No: only if hx of or FHx or symptomatic
What are risk associated with intercourse during pregnancy?
STD, preterm labor due to lower uterine stimuli, Oxytocin released
Routine screen of gestation diabetes should occur?
at 24 weeks
When should a 1st trimester pt w/ chlamydia and Gonorrhea be tx and rescreened
Tx immediately rescreened later even if no sx
what are increased risk of ectopic preg?
prior hx of ectopic, IUD use, Hx of PID, abortion
What medication should be used for UTI in pregnancy?
Macrodantin safe and most efficacious?
What medication is associated with fetal tooth discoloration? ....really?
Doxycycline
Why is ciprofloxacin not recommended during pregnancy?
potential problems w/ bone and cartilage formation
What is myperemesis gravidarum
persistent vomit results in weight loss of >5% (morning sickness is milder)
What is Anhedonia
loss of pleasure in things that use to bring interest, screen for depression
What is the most common S/E of lithium:
nephrogenic diabetes insipidus, plyuria and polydyspia
What is searching behavior after the death of a loved one?
Imagined hearing or seeing deceased...should resolve in 6m no meds needed
CAGE used for
screen for alcohol abuse
CAGE stands for:
C" need to cut down
A: Annoyed by criticism
G: guilty about amount
E: need eye opener.
Usually 2 or more
What are physcial sx of alcohol abuse?
Macrocytosis, due to B12 deficienttremors, HTN, rhinophyma, peripheral neuropahty, telangiectasias, hepatosplenomegaly
What labs are elevated in alcoholics?
Liver enzymes: ALT and AST usually 2x higher than ALT
Which of the following is bulimia nervosa?
bing w/o purge
pruge must be present
loss of control
refusal to eat
loss of control: may involve purge and nonpurge
What are typical S/E of SSRI
Nausea, Ha daily
Elderly tx for depression w/ TCA exhibit?
cognitive changes and urinary retention
Bipolar disorder is associated with high rates of >>.
suicide
What med is indicated for acute mania?
Lithium
What should be monitored when taking valproate for manic sx
Valporic Acid, platelets, LFT. Assess for thrombocytopenia,
Target valproate levels: 50-125
Tx for depression w/ fluoxetine finds out shes pregnant what should the next step be>
Continue w/ medication, let OB and patient make this decision; it does cross placenta
What drugs are associated with a dry cough?
ACE-I
What would be part of the differential in cough?
CHF, GERD, Asthma, URI, ACE-I
How is M. and C. pneumonia respiratory pathogens spread?
via cough
Which patient needs a peak flow?
chronic bronchitis, emphysema, pneumonia, asthma
Asthma: measures peak expiratory flow; sensitive to resp tube changes.
What does FEV1 stand for:
forced expiratory volume in 1 sec. Used w/ emphysema; aveoli are stretched and contain trapped air.
What medications are use to tx COPD? classes
long acting bronchodilators (salmeterol), anti-cholinergic (tiotropium), steroids.
Which of the following is most important to assess w/ new onset asthma?
-smoker?
-how severe r sx?
-How often do sx occur
-do you wheeze?
How often do sx occur? Determines pharm management and frequency.
A 45 yr smoker will most likely have what Chronic respiratory disorder?
COPD
Why are narcotic contraindicated in COPD patients?
decrease respiratory drive and worsen hypercapnia
What is the most common pathogen in atypical pneumonia?
mycoplasma pneumonia
What is the most common pathogen in community acquired pneumonia?
Streptococcus pneumonia: usually post influenza in the very young and old
How many metered doses are in an metered dose inhaler?
200 doses
What is the next step for a pt that is using MDI >2x wks and needs a refill w/ daily maintenance steroid.
Increase the steroid and refill the albuterol. the pt is not well controlled and needs better maintenance
Which of the following is not common in acute bronchitis?
cough, pharyngitis, nasal discharge, fever
Fever.
Cough is the most common lasting >5d. If fever w/ cough then consider pneumonia.
What is the tx for acute bronchitis w/ purulent sputum?
anti-tussive only. Only antibiotics if pertussis. Purulent sputum is epithelial cells sloughing which results in colored sputum.
Which of the following meds are needed in acute bronchitis?
-steroids oral
-antibiotic
-decongestant and antitussive
-antibiotic and steroids
-decongestant and anti-tussive
tx the sx rarely bacterial
What is the recommended max amount rescue inhaler should be used w/ proper asthma maintenance
2xwk day or 2x month at night
Why should you NOT use Timolol (eye medication) in an Asthma patient?
It is a beta-blocker which may precipitate asthma exacerbation
what is essential in dx of COPD
PFT = FEV and FVC (forced vital capacity)
Why should ipratropium (atovent) not be used w/ beta blockers unless short of breath?
Beta agonist increase side effects like tachycardia and treemors w/o improved efficacy
Why is asthma not listed under COPD diseases?
Asthma is reversible COPD is not.
Which organism in pneumonia has rust colored sputum?
Strept pneumonia
What major lab is found in pneumonia?
leukocytosis: gram stain can be pos or neg: leukopenia is an omnious sign in elderly
What is a typical finding on xray w/ pneumonia?
inflitrates: w/ fever, CP, dyspnea, sputum
Mycroplasma pneumoniais present as what type of pneumonia and what are the sx and what does the xray reveal?
atypical pneumonia
varied sx
xray has: thickened bronchial shadow, streaks of interstitial infiltration and atelectasis
What antibiotic can be used empirically w/ pneumonia in otherwise healthy pt
azithromycin or augmentin
What are sx of trichomonas in males
no sx in males:
Females: itching and discharge
Tx w/ metronidazole (flagyl)
Chancroid is an STD from H. Ducreyi what is it a co-factor STD w/:
HIV and heals slower:
males have pain females dont
21y/o w/ HPV lesions on vulva what is the tx:
trichloroacetic acid: warts will slough off after 1 or more tx
What test are ordered after + HIV results?
CD4 and HIV RNA (viral load): norm CD4 500-1500, at 200 dx w/ AIDS
How often should viral counts (CD4) be monitored?
every 3-4 months (2-8 wks when changing therapy) Sx do not affect CD4 counts
What medications are used for trichomoniasis
metronidazole
Which risk factor has greatest impact on HIV transmission?
viral load
-type of sex
-presence of STD
-patient gender
Viral load
How long after a needle stick will seroconversion occure?
4-10wks
Pt neg for HIV but exposed 4m ago. When should she be retested?
no recommendation for futher testing. Window period is w/in 3 mnths of exposure if neg after then neg
What is the primary reservoir for HIV?
lymphatic tissue
If someone has persistent generalized lymphadenopathy what should be tested?
HIV
What clincal syndrome is from replacement of normal vaginal flora?
bacterial vaginosis
Male patients presents w/ dsyuria what is the likely STD?
Chalmydia and gonorrhea
Dx w/ genital herpes, what will be prescribed?
valacyclovir
Suspected of syphilis needs a _____ screening
serum assessmetn RPR
72y/o early renal insufficiency: what lab do you expect
serum creatinine is sligtly elevated: protein would not be specific for renal disease
A pt w/ a long hx of HTN dx w/ chronic renal insufficiency: What would dx test reveal?
clear urine & elevated creatinine: clear because kidney cant filter content.
What organ is responsible for erythropoietin production:
kidney
When is the only time asymptomatic bacteria treated?
During pregnancy to prevent UTI, or other immunosuppressive state
What diagnostic diagnosis a UTI
urine bacteria >100,000, midstream, clean catch
What is murphys sign
inspiratory arrest w/ deep palpation of upper right quadrant (cholecystitis)
Are males or females more likely to suffer from urolithiasis?
males: sx of fever, chills, RBC casts are mucoprotein complexes
24y/o female patient dx w/ uncomplicated UTI. What is important and is least important assessment?
Body temp, abd exam, CVA tenderness, vag exam
body temp, abd exam, CVA tenderness: Vag exam would not be indication unless vag discharge
How long should a UTI be tx w/ septra?
3 days
Male w/ sx of burning w/ urination. what assessment is least important?
abd exam would be least important: diff dx: urethritis, epididymitis, prostatitis, STD
Acute Mnt Sickness:
Onset, sx, PE:
1-6hrs-several days, rapid
Sx: Ha, cough, anorexia, nausea, weakness, insomnia
PE: increased HR, decreased BP, fluid retention
Acute Mnt sickness:
Tx, Prevention
Tx: descend >500m, acclimatize, acetazolamide (diamox), emetics, analgesics
Prevention: Ascend slowly, avoid strenuous exertion and rapid ascent, consider acetazolamide 1 day prior and 2 days after ascent, spend night intermediate altitude
High-altitude pulmonary edema:
tx
descent, rest evacuation, nifedipine (CCB), oxygen, hyperbaric bag
High altitude cerebral edema:
Tx
descent evacuaiton, dexamthasone, hyperbaric bag, BLS, seizure control
What immune response results in anaphylaxis?
immunoglobulin E (IgE): bronchospasm, hypoxemia, hypotension. basophil and Mast cells
What immune response indicates severe rxn?
facial angioedema, resp distress, vascular collapse
What is a biphasic reaction?
Primary rxn 1-45 min after exposure then sec rxn hrs after exposure.
What medication is used for anaphylaxis?
IM Epi (0.3-0.5 of 1:1000) q 15min
-0.01mg/kg children (vastus lateralis)
-diphenhydramine: 50-100mg Po or IM if severe,
-Ranitidine 50mg IV
-Hydrocortisone for delayed relief: 100mg q6hr for relapse prevention
What test can ID allergens:
RAST: radioallergosorbent
Mosquitoes, flies: presentation
pruritic, painful papule, secondary infection common
Bedbug, kissing bug: presentation
clustered, erythematous, purutic nodules
Fleas: presentation
pruritic grouped welts, papules, vesicles, secondary infection common
Lice: presentation
pruritus, nits in scalp, body or pubic hair
Centipedes: presenation
pain an ditching w. local necrosisi
millipedes: bite presentation
brown stain w/ blistering
Scabies: Presentation
burrow lesion w/ pruritus, secondary infection, usually in webs of fingers and hands
Chiggers: presentation
pruritic papules or vesicles, secondary infection
Ticks: presentation
pruritic papules w/ tick present
Tx of lice and scabies includes:
1% lindane lotion or Kwell, scbene shampoo 2 consecutive nights, consider permethrin for scabies also
What is a good repellent to prevent outdoor insect bites?
diethyltoluamide (DEET) or Indalone
Describe a Brown Recluse and tx:
length 5x width, yellow, brwn or black, thin legs, violin shaped marking, supportive tx, or surgical if >2cm
Describe a Black widow and tx
female most venmous, black, brwn, tan, may or may not have hour glass, tx: supportive, tetanus, pain relief (calcium gluconate)
What are presentation of coral snake bite sx?
salivation, dysarthria, diplopia, dysphagia, dyspnea, seizures- 6hr after bite.
What is the tx for snake bites and scorpion stings?
calm, immobilze, minimize physical activity, wipe bite, BLS, tetanus, antivenom for snakes. Observe for 12 hrs
What is the mainstay of GI decontamination in overdose or chemical ingestion?
activated charcoal 1-2 g/kg: DONT use in caustic acids, alkalis, alcohols, lithium or heavy metals
What is the tx for ethylene glycol
Ethanol 10% in D5W, over 30min, then maintain blood alcohol at 100-150mg/dl
Electric injury: Which is more dangerous AC or DC
AC alternating current = tetanic skeletal muscle contraction prevents letting go of engergized source
Acids (toilet cleaner, drain, hydrocholric, sufuric, batter acid)
Sx, Tx
Sx: burns of oral mucosa, drooling, odynophagia, abd pain
Tx: Sucralfate 1g PO
-copiously wash mouth. DO NOT induce vomiting, lavage or administer charcoal
Alkalis: Sx, Tx
Sx: caustic-burns
Tx: dilution w/ water, DO NOT induce vomit, lavage. Ingest large amounts of waster or milk, avoid emesis
Anticholinergic exposure: Sx, Tx
Sx: flushing skin, vlurred vision or mydriasis, tachy mucous membrane
Tx: physostigmine, 0.5-2.0 IV or IM
Carbon Monoxide: Sx, Tx
Sx: HA, cherry lips, altered consciousness, coma
Tx: Oxygen, 100% hyperbaric chamber
Ethylene glycol: Sx, Tx
Sx: cough, dizziness, HA, abd pain, dullness, N/V
Tx: Ethanol, 10ml/kg of 10% ethanol solution over 30min
Isopropyl alcohol: Sx, Tx
Sx: Ethyl alcohol-like (ETOH-like) (altered consciouness, stupor, slurred speech) dizzy, GI, coma
Tx: lavage charcoal, no not vomit, lavage w/in 30min ingestion: may require dialysis
Methanol: Sx, Tx
Sx; cough, dizzy, HA, nausea, dry skin, redness
Tx: Ethanol: same as E. glycol
Petroleum products: Sx, Tx of ingestion
Sx: vomiting, chest or abd pain, cough, dyspnea, fever, arrhythmia, seizures, LOC
Tx: Prompt lavage, O2, ipecac in alert, intubate
Head Trauma: Glasgow coma:
Eye opening scoring
spontaneous 4
verbal: 3
pain: 2
no response: 1
Head trauma: Glasgow com:
Best motor response
obeys verbal: 6
localizes pain: 5
movement or w/drawl to pain: 4
flexion to pain (decort): 3
extension to pain (decerb) 2
no response: 1
Head Trauma: Glasgow Coma
Best Verbal:
A&O: 5
Converse but confused: 4
Nosense/inappropriate words: 3
nonspecific sounds: 2
No response: 1
What is the cascade effect of cerebral edema?
increased ICP=> decreased cerebral blood flow => cerebral ischemia
What diagnostics should be used on Head Injuries:
xray for cervical, CT for depressed or deteriorating LOC, LOC <5min, amnesia, GCS 12-14, depressed skull
What is the most important time after a head trauma?
following the initial stabilization: 24hrs after are the most important for cerebral swelling
What are steps would require a head injury to return to the hospital?
drowsiness difficult to awake, continuous nausea, vomiting more than twice, seizures, pupillary changes, weakness, severe HA, dizziness.
What is postparandial hypotension?
hypotension after meals (mostly in elderly due to rush of blood to abdomen)
What fluid challenge should you give someone w/ hypovomlemia
250-500ml of NS IV
What head elevation should there be in a person sleeping w/ hypotension?
10-20 degrees for sleep
Does cocaine interfere w/ reactivity of pupils?
no but antichoinergics causes unreactive pupils
What medications cause nystagmus?
alcohol, lithium, tergretol, meprobmate, primidone
What medication is given for benzo overdose?
Flumazenil (0.2mg q 1min)
Sexual assault: definition
sexual act that is forced or coerced w/o consent of victim
What should you do if a patient has been sexually assaulted w/in the last 5 days?
defer physical exam and refer to ER if the patient wants to pursue legal action. If > 5d or no legal then manage in the office
What is the time limit to offer pregnancy or STD prophylactics:
72 hrs
What STD test should be performed on a sexual assault?
gonorrhea, chlamydia most prevelant. Test for HIV/AIDs cannot be doen until 3-6months due to seroconversion
What percent of sexual assault victims will have PTSD?
1/3rd
How are tilts performed:
lie, sit stand for 5 min each w/ BP and pulse: drop systolic by 20 , diastolic by 10 and increase pulse 20.
What is passive external rewarming:
placing patient i warm environment
What is active external rewarming:
hot blankets, hot packs, warm bodies, forced air rewarming
What is core rewarming?
warem IV fluids, heated and humidified oxygen, body cavity lavage
What temperature of water should frostbite extremities be warmed?
98.6-104F: also give motrin, topical alovera to decrease inflammation, Tetanus, IV PNC: at 500kU
How long does it take to acclimate to warm climates:
7-14 days
How does Cushings develop?
ACTH-secreting tumors of the pituitary or small cell lung carcinomas which elevate Cortisol and ACTH levels.
What is a pheochromocytoma?
tumor of chromaffin cells, unilateral --> abnormal production of epi and norepi-->Na retention, reduced hydrostatic..
What is the exception to Addisons presentation of slow onset?
inadequate supplement of corticosteroids (chronic users of corticosteroids --> addisons)
Sx of Cushings:
sudden weight gain, loss of menses, decreased libido, depression bruising.
What diagnostic is critical upon the dx of Addision to r/o another disease?
chest xray to rule out TB
How is Cushings syndrome most accurately dx?
24hr excretion of cortisol in urine
What diagnostic confirms pheochromocytoma?
elevated catecholamines in 24hr urine
What sequal events may occur w/ Addisions?
eating disorders, alcoholism, malnutrition, HYPERTHYROID, diabtes, apathy, depression
What is the tx of chronic adrenal insufficiency (Addisions)?
oral hydrocortisone 20-30mg/d (consider mineralocorticoid replacement to correct renal and hypotension.
What is the first choice in managment of Cushings?
Pituitary tumor resection w/ chemo
What are complications of Cushings?
osteoporosis, hypertension, diabetes
DM 1 what is the the problem?
beta cell destruction and requires exogenous insulin
What is the Problem w/ DM2?
beta cell dysfunction and/or insulin defect
What causes fasting hyperglycemia?
increased hepatic glucose production in the impaired early stage of insulin secretion
What causes Postprandial hyperglycemia?
Decreased uptake of glucose from skeletal muscles
How often should a new or uncontrolled DM1 or DM2 be seen?
every 3 months, extended to 6 if well controlled
How often should a diabetic get an A1C?
ADA: twice a year at a minumum or every 3 months if glucose not controlled
How often should microalbumin be obtained in DM?
yearly after 5 yrs of DM1
Yearly after onset DM2
What is the definitive test to assess kidney function?
24hr creatinine clearance
What does the basal phase do in glycemic control?
Inhibits glycolisis and gluconeogenesis and maintains insulin steady state
What is morning hyperglycemia controlled by? basal or prandial insulin
Basal insulin
Why is Symlin used in diabetes?
it reduces amount of food consumed and slows gastric emptying. Injected before the meal
What are the recommended before meal glucose readings in DM?
70-120mg/dl
What are the postprandially glucose goals in diabetes?
<140mg/dl 2hr after meal
What is the recommended begining dose of insulin for DM1?
20u in morning before breakfast, if fasting of 250 then 5U before bedtime snack.
What medication mimics the effects of basal insulin?
Glargine 24hr long acting no peak
How often should insulin dose be adjusted and when can adjustment stop?
adjust every 3-4 days until fasting glucose is <110mg/dl; only increase by 2-8U if obese and 1-4 if thin
What is professional scope of practice?
Address role, function, population, practice setting. Serve as the initial source to define individual scope of practice (TBON)
What is the wording used when an APRN directs another nurse to a specific task? Delegating or assigning
APRN are only allowed to delegate assitive personnel they may assign another nurse
What is the process of receivign prescriptive authority for controlled substance?
TBON authority, TDPS registration, DEA registration number.
What level of controlled substance may an APRN provide?
schedule III, IV, V
What is the maximum period that a controlled substance may be prescribed for by an APRN?
30 days
Can an APRN refill a prescription?
Yes but only after consultation and documentation w/ a delegating physician. (TBON)
What is the minimum age a controlled substance may be prescribed by an APRN?
2y/o if younger then consultation is required w/ documentation
If tx migraines w/ abortive therapy what is the max time to use tylenol, NSAIDs?
2d/wk to prevent analgesic rebound: can make HA daily condition
What is the tx of urge incontinent (pharm)
Anticholinergic medicines help relax the muscles of the bladder. They include oxybutynin (Oxytrol, Ditropan), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), and solifenacin (Vesicare).
These are the most commonly used medications for urge incontinence. They are available in a once-a-day formula that makes dosing easy and effective.
The most common side effects of these medicines are dry mouth and constipation. People with narrow-angle glaucoma cannot use these medications.
Flavoxate (Urispas) is a drug that calms muscle spasms. However, studies have shown that it is not always effective at controlling symptoms of urge incontinence.
Tricyclic antidepressants (imipramine, doxepin) have also been used to treat urge incontinence because of their ability to "paralyze" the bladder smooth muscle
Addisons, Cushings, and Pheochromocytoma are disorders of what?
Adrenal Gland
What is Addison's disease?
chronic endocrine disorder in which the adrenal glands do not produce sufficient steroid hormones (glucocorticoids and often mineralocorticoids
What is the tx of addison's?
Life long replacement of steroids...hydrocortisone and fludrocortisone
What is found in Addison's Crisis?
snycope, hypoglycemia, leg pain, low B/P, lethargy, hypokalemia, fever, convulsion
Why and how long should you avoid alcohol when taking metronidazole (flagyl)?
24hrs: avoid disulfiram-type rxn (severe n/v)
What do you do if a pt fails tx on flagyl for trichomoniasis?
Retreat w/ flagyl 500mg
What antibiotics are used for acute prostatitis?
Septra and fluoroquinolones
(PNC and Cephlosporins can not be used because they cant penetrate the prostatic epithelium)
What is the most common cause of hyperthyroidism
Graves disease: abnormal immune response -->thryoid produces too much thyroid hormone T4, T3
What are sx of B. pertussi?
paroxysmal cough lasting >2wks
What population is considered + TB at >5 induration?
HIV, Recent TB contact, CXR w/ fibrotic change, organ transplant, Immunosuppressed
What population is + TB w/ >10mm induration?
<5yr immigrant, IV drug, congregate setting, lab personnel, peds<4y/o, peds exposed to high risk
What population is + TB w/ >15mm induration?
Everyone
Tx of CAP w/ no comorbidity?
Macrolide: azithromycin, clarithromycin, erythromycin
Tx of CAP w/ comorbidity?
Respiratory fluoroquinolone (levofloxacin)
OR
advanced macrolide plus beta-lactam: Augmentin, Rocephin,
Alternative to macrolide: Doxy
How is Legionella for pneumonia spread?
inhalation of contaminated water
The most common pneumonia is Streptococcus pneum. What is it resistant too?
beta-lactams (PNC), Macrolides (emycin, clarithro, azithro), tetracyclines (doxy).
Known as drug-resistant S. pneum (DRSP)
What antibiotic should be used against DRSP (drug resistant S. Pneumonia)?
respiratory fluoroquinolones (levoflaxacine [levaquin])
What type of pneumonia organism is seen in alcoholics?
Klebsiella pneumonia
How do you know if a sputum sample is adequate for testing?
Few Epithelial cells w/ many WBC (epithelial will come from throat not lungs)
What medication may be given to latent TB if isoniazid is not tolerated? How long?
Rifampin (6-9m)
What is meant by long-term oxygen therapy in COPD?
>15hrs day w/ oxygen
If a person has a persistant cough that is controlled by a bronchodilator what is the dx?
asthma
Which environment is more likely to induce asthma sx. A warm humid space or a cold dry space?
Cold dry space
What are the three components of asthma dx?
1. episodic sx of airflow obstruction (wheeze)
2. evidence of at least partial reversible (improves w/ med)
3. exclusion of other conditions
What diagnostic tool is essential in the dx of asthma?
spirometry: Should be 80-100% expected:
Volume or speed/flow of air that can be inhaled and exhaled
How often should microalbuminuria be obtained in DM w/ neg protein?
Annually
When giving biguanide what should you monitor? CK, ALP, ALT, Cr
Cr-creatinine:
Secondary causes of hyperglycemia include all except?
niacine, corticosertoids, thiazide, angiotensin receptor blocker
Angiotensin receptor blocker
A1C provides info on glucose control over what period of time?
21-47d, 48-63d, 64-90d, 90-120d
90-120 d...or 3 months
If taking the following insulin at 8am what time would you expect the peak to occur?
1. Lispor, 2. Reg Insulin 3. NPH insulin, 4. Lantus
1. Lispor: 30m-1hr
2. Reg Insulin: 2-3hr
3. NPH Insulin: 4-6hr
4. Lantus: no peak (24hr coverage)
What do meglitinide minimize in type 2 DM
Pstparandial hyperglycemia
What is a common adverse effect of alpha-glucosidase inhibitor:
Gastrointestinal upset
What are steps to improve microalbuminuria?
1. improve glycemic control
2. strict dyslipidemia control
3. use ACE-I or ARBS
How often should A1C be checked in those w/ stable glycemic control?
twice a year (every 6m)
What is the mechanism of action of sitagliptin (Januvia)?
Increase incretin -->increase synthesis and release fo insulin from pancreatic beta cells.
What is the mechanism of action for Byetta?
Stimulates insulin production in response to increase plasma glucose
What DM med should be avoided if hx fo gastroparesis?
exentaide (Byetta): mainly due to its S/E of n/v/d with regular use
What are recomended tx of HTN w/ type 2 dM?
Beta blockers, ACE-I, ARBS; NOT alpha blocker
What do expect to find when giving a fibrate?
increase HDL
What do you expect to find when giving niacin for lipids?
increase HDL
What do you expect to find when giving Zetia for lipids?
reduction in LDL
With Zetia (ezetimibe) what should routinely be monitored?
No need to monitor labs...little impact on liver or kidney
Which of the following man not causes statin-induced myositis?
advanced age, use of statin w/ resin, low body weight, high statin dose
Us of statin w/ resin is not a risk for myositis
Which of the following is most effective against lipidprotein?
1. HMG-CoA reductase inhibitors
2. Niacin
3. bile acid
4. fibrates
2. Niacin
What can untx hypothyroid lead to in lipid profile?
increased LDL, TC, and Trig
What should rigorous physical exercise do to lipid values?
increase HDL, Lower VLDL, Lower Triglycerides
What should you expect to see when giving fish oil?
decrease triglycerides
What should you expect to see when giving Plant stanol and sterold on lipid profile?
decrease LDL
How much eicosapentaenoic acid and doccosahexaenoic acid (omega-3) per day should you prescribe?
1G (preferably from fish oil)
Obestity is defined as BMI >
30kg/m2
When using orilstat (Alli) when should you take the medication?
w/in one hour of each meal w/ fat
What is responsible for satiety?
1. norepi
2. epi
3. dopamine
4. serotonin
Serotonin
What are adverse effects of sibutramine (Meridia)?
somnolence
Which med is associated w/ weight gain?
1. risperidone (Risperdal)
2. topiramate (topamax)
3. metformin
4. phentermine
Risperidone: tx schizo
If walking 8000-10000 steps/day what is the milage?
4-5miles
What medication is used to reduce craving for alcohol?
acamproste (Campral)
What medication is used to modify intoxicating effects of alcohol?
naltrexone (ReVia)
What medication results in unplesant adverse effects of alcohol?
anabuse
What happens to RBC in alcoholics and why?
become macrocytic due to reduction in folate
Define Acromegaly
Excessive growth hormone: excessive bone and soft tissue growth