Amarina Study Guide 20
Amarina Study Guide 20
REVIEW - AANP
Document created using Leik, Hollier and Fitzgerald – I do not own the copy rights to images, etc.
Ø Prostate Cancer
US PREVENTATIVE SERVICES TASK FORCE CANCER PREVALENCE
o Benefits of PSA screening do not
Ø Aspirin use to prevent cardiovascular disease and Ø Skin cancer is most common cancer
outweigh the disadvantages
colorectal cancer o Basal cell carcinoma
o Risk factors:
o Age 50-59 with >10% ASCVD o Melanoma highest mortality
§ Age > 50
Ø Breast Cancer Ø Men – prostate cancer
§ African ancestry
o Mammography age 50-74 (every 2 years) Ø Women – breast cancer
§ First degree relative
o Risk factors (start age 40 or BRCA1/2) Ø Gynecological
Ø Ovarian Cancer
§ Previous hx of breast cancer o Uterine/endometrial
o Routine screening not recommended
§ >2 first-degree relatives o Ovarian
o BRCA1/BRCA2 mutations – refer to
§ Early menarche, late menopause, Ø Children – acute lymphoblastic
specialist
nulliparity leukemia (ALL)
Ø Skin Cancer Counseling
§ obesity
o Recommend for those with fair skin
Ø Cervical Cancer
Ø Abdominal Aortic Aneurysm
o Age 21 – screen every 3 years
o Men age 65-75 who have smoked
o Age 30 – screen with HPV every 5 years
o One-time ultrasound MORTALITY
o Hysterectomy with removal of cervix –
Ø Lipid Disorders Ø Leading cause of death (all ages)
only need screening if hysterectomy due
o Start low – moderate statin when all: o Heart disease
to cervical cancer
§ Age 40-74 o Cancer
o Stop screening at age 65
§ CVD risk factor § Men (lung,
o Risk factors:
§ ASCVD > 10% prostate, colorectal)
§ Multiple sex partners
Ø Lung Cancer § Women (lung,
§ Younger age at onset of sex
o Smoke 30 pack-years or quit in last 15 breast, colorectal)
§ Immunosuppression and smoker
years o Chronic respiratory
Ø Colorectal Cancer
o Age 55-80 (annual screening with CT)
o Start age 50-75
§ Colonoscopy every 10 years
ADOLESCENTS
§ Flex sigmoidoscopy or CT OVARIAN CANCER
Ø Death rate for teen males is higher
colonography every 5 years Ø No recommendation for routine screening
than females
§ FOBT (3 consecutive stool Ø In postmenopausal women with palpable ovary
o Accidents (MVC most
samples) annually o Intravaginal ultrasound and CA-125
common)
§ New Cologuard Ø Strongest risk factor is BRCA1 or BRCA2
o Suicide
o Risk Factors Ø Other risk factors include age, obesity, Clomid
o Homicide
§ Familial polyposis use or endometriosis
§ First degree relative w/ colon CA Ø Prostate/testicular cancer screening not
§ Crohn’s (ulcerative colitis) recommended
PHARMACOLOGY
Fluorescein dye
Fern like lines in corneal
surface (corneal abrasions
Acute onset of severe eye pain, photophobia,
Herpes simplex are round or irregularly
tearing and blurred vision in one eye Infection permanently
(Herpes Simplex shaped)
Herpes Zoster Ophthalmicus – acute crusty rashes damages corneal
Herpes Keratitis Keratitis) or herpes Refer to ED
that follow ophthalmic branch (CN V) of epithelium – corneal
varicella zoster (Herpes
trigeminal nerve (one side forehead, eyelids and blindness
Zoster Ophthalmicus)
tip of nose) can result in blindness
Coughing, sneezing,
Subconjunctival heavy lifting, vomiting, Blood trapped underneath the conjunctiva and
Watchful waiting and reassurance of patient
hemorrhage local trauma, sclera secondary to broken arterioles.
spontaneously
Refer to ophthalmologist.
Gradual onset of increased IOP greater than 22 Most common glaucoma.
Check IOP with tonometer. Normal 8 to 21
Elevated intraocular due to blockage of drainage of aqueous humor Blindness due to ischemic
(>30 is very high)
pressure inside eye; most common in elderly; usually damage to retina.
Betimol 0.5% - ↓ aqueous production
Primary Open- Risk factors: African asymptomatic during early stages. Gradual 2nd leading cause of
(beta/alpha blockers)
Angle glaucoma ancestry, Type 2 DM, change in peripheral vision then central blindness
Latanoprost – topical prostaglandin
advanced age, family vision (tunnel vision). May complain of missing Risk factors: postural
SE of med: bronchospasm, fatigue,
hx of POAG portions of words when reading. If cupping of hypotension, hx of fungal
depression, heart failure, bradycardia
optic disc– IOP is too high conjunctivitis, white race
Contraindicated asthma, COPD, heart failure
gradual damage to Asymptomatic in the early stages. Complains of
Refer to ophthalmologist. Pt is given Amsler Most common cause of
pigment of macula gradual or sudden and painless loss of central
Macular grid to check vision loss daily to weekly vision loss. Leading cause
(area of central vision) vision in one or both eyes. Straight lines become
degeneration Atrophic (dry form) or exudative (wet form) of blindness in elderly
results in severe visual distorted or curved (scotoma). More common in
– wet is responsible for 80% Risk factors: age, smoking
loss to blindness smokers
Decreased function of lacrimal and salivary
OTC tear substitute TID
Chronic autoimmune glands. Persistent daily dry eyes and mouth
Sjogren’s Syndrome Refer to ophthalmology, dentist and
disorder (xerostomia) for > 3 months. Eyes have sandy or
rheumatology
gritty sensation. Uses OTC artificial tears TID
HEENT
Red, irritated eye with eyelids that were “stuck Adenovirus is most
Suppurative Pseudomonas Polymyxin B plus trimethoprim,
together” – injected palpebral and bulbar common cause of viral
conjunctivitis aeruginosa levofloxacin, azithromycin
conjunctiva conjunctivitis
Itchy eyes, nose, or throat. Nasal congestion, First line: Remove or avoid allergen. Avoid 1st generation
Nose has blue-tinged or pale
IgE mediated disease rhinorrhea, postnasal drip, sneezing. Cough · Intranasal corticosteroids (down regulates antihistamines due to
boggy nasal turbinates.
due to genetic and worsens when supine. inflammatory response) takes 2-7 days sedation
Mucus clear. Posterior
Allergic rhinitis environmental · Add Astelin. (chlorpheniramine,
pharynx thick mucus with
interactions Pollens – most common seasonal allergen; dust · Cromolyn sodium TID – mast cell stabilizer diphenhydramine,
possibly cobblestoning.
“Asthma in the head” mites – most common perennial allergen; mold · Use decongestants – nasal congestion carbinoxamine,
Undereye circles.
spores – common indoor allergen · Oral antihistamines (block H1) – itch brompheniramine)
Acute onset nasal bleeding. Possible vomiting of Direct pressure. Nasal decongestants (Afrin -
Idiopathic, digitorum,
blood. Anterior nose bleeds (Kiesselbach’s oxymetazoline) – silver nitrate (ouch) Posterior nasal bleeds can
ASA, NSAIDs, cocaine,
Epistaxis plexus) are milder and more common than Apply triple antibiotic ointment or petroleum lead to severe
HTN, anticoagulants
posterior nose bleeds (Sphenopalatine or carotid jelly in front of nose with cotton swabs for a hemorrhage
place pt. at higher risk
artery) few days.
Abrupt onset sore throat, fever, headache, tender, Strep screen PCN V 500 BID-TID x 10 days Viral if cough, rhinorrhea,
Streptococcus
localized anterior cervical lymphadenopathy. Dark CENTOR Score Amoxicillin 500 BID x 10 days coryza (watery eyes).
pyogenes or Group A
pink to bright red pharynx. Tonsillar exudate • Tonsillar exudate PCN allergic: Zpak x 5 days If not treated can cause
beta Strep
yellow to green in color. Petechiae on hard palate. Ibuprofen/Tylenol rheumatic fever – rash is
(incubation is 3-5 days) • Anterior cervical
Scarlet fever or scarlatina (sandpaper-like rash) Salt water gargles, throat lozenges, drink increased risk
Strep throat M. ↑ is often common adenopathy
with strawberry tongue. Rash usually erupts on fluids Post-strep
in teenagers and adults
day 2 and often peels a few days later. • Hx of fever glomerulonephritis –
with same symptoms, • Absence of cough
Most adults do not get strep, but *** If H. influenza - Augmentin or cephalosporin proteinuria, hematuria,
but dry cough Age 3-14 +1; 15-44 0; 45+ -1
immunocompromised or those who have high If M. pneumoniae – macrolide or dk urine, RBC cast, HTN
(incubation 3 weeks) Score > 2 screen for strep
exposure due to job or lifestyle fluoroquinolone edema
Non-severe – watchful waiting; Treat with Bullous myringitis –
Non-severe: mild otalgia <
Otalgia, popping noises, muffled hearing, recent amoxicillin 80-90mg, if recent abx then blisters on red and
48hrs. or fever <102.2 in
Strep pneumoniae cold or allergies. Moderate or severe bulging of Cefdinir followed by Augmentin. (< 2 yrs. 10 bulging TM. Conductive
past 24 hours
Acute Otitis Media H. influenzae TM or new onset otorrhea not related to otitis days, 2-6= 7 days, >6 = 5-7 days) if pt. has hearing loss. Tx same as
Severe: moderate/severe
M. catarrhalis externa (OE); erythema, mild bulging of TM and mono do not give Amoxicillin – will have AOM.
otalgia, otalgia > 48 hrs. or
recent onset of ear pain morbilliform rash; tympanic membrane Expect sensation of ear
fever > 102.2
rupture with hearing loss – Refer to ENT fullness up to 8 weeks
Symptomatic tx: Saline nasal irrigation,
Secondary bacterial HPI- bacterial intranasal corticosteroids, decongestants,
Acute viral Unilateral facial pain or upper molar pain for 10 Watchful waiting: 10 days
infection usually Persistent and not mucolytics
rhinosinusitis days or longer with purulent nasal or post nasal No macrolides
following viral URI improving (>10days); fever First line: Augmentin 875/125 or
(AVRS) drip. Head congestion, fever, sore throat, cough. Treatment 5-7 days =
Strep pneumoniae Severe > 3-4 days 1000/62.5 or 2000/125 BID 5-7 days
Acute bacterial Self-treatment with OTC provide no relief efficacy, fewer
H. influenzae (common Worsening or double Allergy to PCN/Cephalosporin:
rhinosinusitis complications, better
in smokers) sickening Doxycycline 100mg BID or Levofloxacin
(ABRS) compliance
M. catarrhalis transillumination 500mg daily or Moxifloxacin 400mg daily;
Cefdinir, Ceftin, Vantin BID 5-7 days
HEENT
Poor fitting dentures, Slow growing white plaque with firm to hard
Leukoplakia chewing tobacco, surface, slightly raised on tongue, floor of mouth Precancerous lesion refer
alcohol abuse or inside cheek
Largely diagnosis of
exclusion. Horizontal
nystagmus usually towards
Risk factors include: use
the affected ear with rapid Antihistamines such as meclizine,
of ototoxic drugs such as
Present with episodes of vertigo with a sensation correction to midline. Weber antiemetics or benzodiazepines can minimize
aminoglycosides, long-
that the room is whirling about – preceded by lateralizes to unaffected ear. symptoms, thiazide diuretics can decrease
term high dose salicylate
Increased pressure decreased hearing, tinnitus and feelings of Rinne’s AC>BC; performing pressure load in ear and prevent but not treat
use, certain cancer drugs
Meniere’s disease within endolymphatic increased pressure. Characterized by repeat pneumatic otoscopy in attacks. Corticosteroids have also been
and long-time exposure to
system attacks that last minutes to hours and can be affected ear can elicit demonstrated to be helpful
loud noise. Can also have
related to food and drinks, mental and physical symptoms. Romberg + Prevention: avoid ototoxic drugs, protecting
Meniere’s symptoms with
stress and variations in menstrual cycle Fukuda marching step test ears from loud noise and limiting sodium
certain situations but not
is positive with drift towards intake
the disease
affected ear. Dix-Hall Pike is
occasionally also positive
indicating BPPV
SKIN/INTEGUMENTARY SYSTEM
DERMATOLOGY ASSESSMENT TIP
Ø Assess the entire patient, not simply the skin problem.
Consider whether there is transmission/contagion risk.
SKIN LESIONS SKIN CANCER ASSESSMENT
Ø Where did it start? (face, torso, extremities, genitals) Ø Annular – in a ring (Bull’s eye lesion – Lyme A – Asymmetry
Ø How long have you had it? disease) – central clearing B – Border irregularity
Ø Does it itch? Ø Bulla – blisters > 1cm w/fluid (burn) C – Color (brown, black, red, white, blue)
Ø Is the patient otherwise well? Ø Clustered - lesion occurring in a group without D – Diameter >6mm (pencil eraser)
o Disease limited to skin such as rosacea, pattern (herpes) E – Evolving/Elevated (most are new)
keratosis pilaris, seborrheic dermatitis. Ø Confluent or Coalescent- multiple lesions blending
together (psoriasis vulgaris) Ø > 2 features ABCDE 100% sensitive, 98%
Ø Is the patient miserable, but not systemically ill? specific
Ø Cyst – raised, encapsulated fluid filled lesion
o Itch, burning, pain – scabies or shingles Ø Melanoma: dark colored moles with
(intradermal lesion)
Ø Is the patient systemically ill with constitutional Ø Lichenification – skin thickening usually found uneven textures – may be pruritic
symptoms (fever, fatigue, loss of appetite, unintended over pruritic or friction areas Ø Acral lentiginous melanoma: most
weight loss, malaise)? Ø Linear - lesion distribution in streaks (poison ivy) common in AA/Asian. Nailbeds,
Ø Macule – flat non-palpable are of discoloration palms/feet
o Varicella, transepidermal necrosis, Lyme
Ø Subungual hematoma: direct trauma to
disease, systemic lupus erythematosus <1cm (freckle)
nailbed causing bleeding between bed
Ø Primary lesions only? Primary and Secondary? Ø Maculopapular – both color and small papules or and finger – trephination – draining the
o Where is oldest lesion - when did it occur? raised skin lesions ranging from erythematous to nailbed
bright pink
o Where is newest lesion – when did it occur?
Ø Nodule – solid lesion > 0.5 – 2 cm (> 2 cm tumor)
o Primary – result from disease process, has not Ø Papule – solid elevation <0.5 cm (mole)
been altered by outside manipulation or tx o Smooth papule dome shaped with central PRESSURE ULCER
§ Ex: vesicle – fluid filled < 1 cm umbilication with white plug (molluscum
Ø Stage I: nonblanchable erythema on
(varicella, shingles, herpes) contagiosum)
intact skin
o Secondary – lesion altered by tx or Ø Patch – flat, nonpalpable area of skin discoloration
Ø Stage 2: presence of epidermal or dermal
progression of disease larger than macule (vitiligo)
skin loss; can appear as intact blister
Ø Petechiae – < 1cm (thrombocytopenia)
§ Ex: Crust – raised lesion caused by Ø Stage 3: full-thickness skin loss with
Ø Plaque – elevated, variable shape >1cm (psoriasis)
dried serum and blood remnants, exposure of some amount of fat, ulcer
Ø Purpura – flat, red-purple discoloration that does
develops when vesicle ruptures has crater-like appearance
not blanch with pressure
Ø Stage 4: full-thickness skin and tissue loss;
Ø Pustule – vesicle like lesion with purulent content
would exposes muscle, bone and tendons
(impetigo)
SMALLPOX Ø Reticular – netlike cluster
Ø Scale – raised superficial lesions that flake with
Ø “Eliminated” 1977
ease (dandruff)
Ø Infection targets respiratory and oropharyngeal
Ø Scattered – generalized over body without specific
surfaces. Incubation period of 2 weeks.
pattern (viral exanthem – rubella/roseola)
Ø Flu-like signs and symptoms with large nodules in
Ø Vesicle – clear fluid (herpes)
center of face, arms and legs. Symptomatic treatment
Ø Wheal – circumscribed area of skin edema
Ø Mortality rate 20-50%
(urticaria)
Ø If vaccine given within 3-4 days postexposure, can
lessen severity of illness
SKIN/INTEGUMENTARY SYSTEM
RANDOM FACTS
o Bed bugs: do not infect the patient
LICHEN PLANUS
o Squamous cell carcinoma: sun exposed areas, lower lip common in smokers Ø Small, flat red to purple bums with
• Presents as papule, plaque, nodules, smooth, hyperkeratotic or ulcerative lesion white scales
Ø Itch – common on wrist, forearms,
• May bleed easily
ankles
• Definitive diagnosis is biopsy or excision of specimen – moles procedure?
Ø Common causes include Hepatitis C –
§ N - nodular
self-limiting
§ O - opaque
§ S – sun-exposed
§ U - ulcerating
§ N – nondistinctive borders ODE TO MRSA
o Irritant contact dermatitis – contaminated water, soaps and detergents, fiberglass, Ø ABCD
particulate dust, food products, cleaning agents, lubricants, oils, coolants, solvents, plastics, o MRSA
resins, petroleum products o Bactrim
o Allergic contact dermatitis – poison ivy, rubber, nickel, fragrances o Clindamycin
o Doxycycline
SKIN/INTEGUMENTARY SYSTEM
Rare reaction to
Lesions like “bulls-eye”, erupt suddenly
medications (NSAIDs, Toxic Epidermal
Erythema Hives, blisters, petechiae, purpura, hemorrhagic
Sulfa, antiepileptic), Necrolysis (TEN) (>30%
Multiforme lesions and sloughing of epidermis. Could have
infection (herpes or of skin) allopurinol,
(Stevens-Johnson prodrome of fever with flulike symptoms 1-3 days
Mycoplasma anticonvulsants, sulfa,
syndrome) before rash appears (palmar rash)
pneumoniae) and NSAIDs
malignancies
SKIN/INTEGUMENTARY SYSTEM
Skin infection involving hair follicle and I & D and warm soaks
Cutaneous abscess, Staph Aureus
surrounding tissue (heat, redness and discomfort) C&S Bactrim, Doxycycline or clindamycin Bactroban for folliculitis
furuncle, carbuncle (MSSA or MRSA)
Carbuncle – multiple abscesses MSSA: Dicloxacillin or Cephalexin
Analgesic or NSAIDs
Painful blistering on side of finger or cuticle Acyclovir for severe infections
Herpetic whitlow HSV 1 or 2
Direct contact with cold sore or genital herpes Avoid sharing personal items, gloves, towels.
Cover skin lesion until healed
Oval plaque with central salmon-colored area and
dark red peripheral zone on anterior trunk.
None – self-limiting (6-8 weeks) Rule our secondary
Pityriasis Rosea Unknown may be viral Fine scales following skin lines: “Herald patch” or
May need something for itching syphilis
“Christmas Tree” patch
Koplik spots
Severe pruritic rash, worse at night, between webs Permethrin 5% cream to entire body – wash
of toes and fingers, axillae, waistline, groin, Wet mount of scraped rash off after 8-12h
Avoid Kwell due to
Scabies Sarcoptes scabiei breasts, butt, penis to view eggs under Treat everyone in household;
neurotoxicity
Rash appears in linear burrows – can last up to 4 microscope clothes/bedding should be washed in hot
weeks water
Capitis – head (most common)
Pedis – foot OTC topical “azole” or allylamines
Tinea Infections –
Corporis/Circinata – body KOH slide for hyphae and (terbinafine, butenafine)
ringworm yeast
Cruris – jock itch spores Gold standard: griseofulvin (baseline LFT
(Dermatophytosis)
Manuum – hands and repeat 2 weeks after initiating meds)
Barbrae – beard
MURMURS GRADING OF MURMURS
Ø Turbulent blood flow through great vessels or across a heart valve Ø GRADE I/VI – barely audible
Ø Timing of murmur – systole or diastole Ø GRADE II/VI – audible but faint
Ø Location of murmur – aortic or mitral Ø GRADE III/VI – moderately loud, easily heard (as loud as S1)
Ø Systolic murmurs – MR Peyton Manning AS MVP Ø GRADE IV/VI – loud, associated with a thrill
o Mitral Regurgitation- “pan systolic”/ holosystolic. Heard at
Ø GRADE V/VI – very loud, heard one corner of the stethoscope off the wall
apex, radiates to axilla, loud or high-pitched blowing (use
diaphragm) Ø GRADE VI/VI – loudest, heard without a stethoscope
o Physiologic Murmur-
§ Hemic like in severe anemia, dehydration
§ Becomes louder when lying down STETHOSCOPE
o Aortic Stenosis- second ICS to right of sternum, radiates to Ø Bell – low tones (S3, S4), mitral stenosis
neck, harsh/noisy murmur (use diaphragm) – avoid physical Ø Diaphragm – mid to high pitch tones, lung sounds, mitral regurgitation,
exertion due to ↑ risk sudden cardiac death; monitored by aortic stenosis
echo and surgical valve replacement; LVH; congenital defect in
kids; acquired could be from prior rheumatic fever; angina,
syncope, heart failure
o Mitral Valve Prolapse- mid to late systolic murmur with mid
HEART SOUNDS
systolic click
Ø Motivated Apples
Ø Diastolic murmurs – ARMS
o Motivated – systole – S1 closure of AV - mitral/tricuspid valve (lub)
o Aortic Regurgitation- high-pitched, second ICS to right of
§ M (mitral valve)
sternum blowing (use diaphragm)
§ T (tricuspid valve)
o Mitral Stenosis- low pitched, apex of heard or apical area; also
§ AV (atrioventricular valves)
called “opening snap” “crescendo” (use bell)
o Apples – diastole - S2 closure of semilunar - aortic/pulmonic valves
Ø All diastolic murmurs – abnormal
(dub)
Ø APETM (valve locations)
§ A (aortic)
o Aortic – 2nd ICS right upper border sternum
§ P (pulmonic)
o Mitral – apex or apical area of heart, PMI, 5th left IC space
§ S (semilunar)
Ø If radiates to axilla the mitral valve is closest to axilla
Ø S3 - Pathognomic for CHF; possible normal for adolescent athletes and
Ø If radiates to neck the aortic valve is closest to neck
pregnancy; possible thyrotoxicosis; always abnormal if occurs >35yo
Ø If a valve fails to open it is stenotic
“Kentucky” – best heard at pulmonic area (AKA ventricular gallop or S3
Ø When a valve fails to close it is incompetent
gallop)
Ø S4 – LVH; normal finding in some elderly; occurs late is diastole and best
heard at apex with bell (Tennessee) (atrial gallop or atrial kick); poorly
controlled HTN; unstable angina
Ø Split S2 is best heard at pulmonic area – healthy athlete
CARDIOVASCULAR SYSTEM
ADDITIONAL PEARLES
Ø BP = HR x SV x PVR
Ø Left side of heart is higher level arterial system – right side is lower pressure thus
abnormalities in the cardiac exam are more likely to arise from left-sided heart
problems
Ø Deoxygenated: Superior vena cava → right atrium → tricuspid valve → right
ventricle → pulmonary valve → pulmonary arteries → lungs (RBCs pick up
oxygen and release carbon dioxide in alveoli) Oxygenated: pulmonary vein →
left atrium → mitral valve → left ventricle → aortic valve → body
Ø Left ventricle is most likely cardiac chamber to hypertrophy
o Left ventricular hypertrophy is common form of HTN TOD
o PMI shift (downward and lateral) common in LVH (normally heard at 5th
ICS MCL)
Ø 2nd chamber most likely to hypertrophy is left atrium
Ø Common pathologic murmurs to arise due to aging – aortic stenosis
Ø Most common regurgitate murmur – mitral regurgitation (mitral valve
incompetent – means it doesn’t close properly) which causes decreased cardiac
output
o Symptoms of low cardiac output
§ Dyspnea with exertion
§ Chest pain
§ Orthopnea (virtually never respiratory, almost always heart
failure – could be LVH and mitral regurgitation)
§ Syncope and near-syncope (when cardiac, generally caused by
aortic stenosis or hypertrophic obstructive cardiomyopathy)
§ Idiopathic hypertrophic subaortic stenosis – type of
cardiomyopathy – autosomal-dominant pattern
o Cardiac exam in mitral regurgitation (MR) includes holosystolic murmur
with blowing quality typically GR II-III/IV with predictable pattern of
radiation to the axilla
§ Holosystolic – takes up all of systole and is the same intensity
throughout systole
Ø Sudden unexpected finding on exam- how did I miss this in health history?
o Onset
o Location/radiation
FIBRINOLYSIS CONTRAINDICATION: o Duration
Ø Absolute: prior intracranial hemorrhage, cerebral vascular lesion, neoplasm, o Character
ischemic stroke in last 3 months, aortic dissection, active bleeding, intracranial or o Aggravating factors
intraspinal surgery within 2 months, severe uncontrolled HTN o Relieving factors
Ø Relative: chronic uncontrolled HTN, significant HTN on presentation, ischemic o Timing
stroke < 3 months, traumatic or prolonged CPR, major surgery within 3 weeks, o Severity
recent internal bleeding within 2-4 weeks, non-compressible vascular punctures,
pregnancy, active peptic ulcer disease, oral anticoagulant therapy
CARIOVASCULAR SYSTEM
LOOP DIURETICS
Ø Furosemide (Lasix)
TARGET ORGAN DAMAGE: JNC-8 GUIDELINES Ø Bumetanide (Bumex)
Ø Eye: hypertensive retinopathy with risk of Ø Implement lifestyle interventions Ø Inhibits sodium-potassium-chloride
blindness (silver, copper wire arterioles, AV Ø Set BP goal pump of kidneys (↑ UO)
nicking, flame shaped hemorrhages – black o Anyone with diabetes or CKD < 140/90 Ø Electrolyte imbalance, hypokalemia,
dots in visual field; papilledema) o No diabetes or CKD
Ø Kidney: microalbuminuria, proteinuria, ↑ hyponatremia, hypomagnesemia
§ <60 yrs. <140/90
creatinine, ↓ GFR, edema § >60 yrs. <150/90
Ø Cardiovascular: S3 (CHF), S4 (LVH), carotid Ø Non-AA – thiazide or ACEI/ARB or CCB alone or in combination
bruits, CAD, MI, LVH, PAD or PVD Ø AA – thiazide or CCB alone or in combination ALPHA-1 BLOCKER “-OZIN”
Ø Brain: TIA, CVA Ø CKD – ACEI or ARB alone or in combination with other class Ø Used for BPH and HTN
Ø Maximize dose of 1st med or add 2nd med or start with combo Ø First dose may cause orthostatic
drug. hypotension, dizziness, postural
LIFESTYLE MODIFICATION FOR HTN/DYSLIPIDEMIA: hypotension
Ø Stop smoking. Reduce stress level. Ø Give at bedtime, start low, titrate up.
Ø Weight reduction if overweight/obese Ø Terazosin (Hytrin), Tamsulosin
o 5-20mm hg per 10kg THIAZIDE DIURETICS (Flomax)
Ø DASH eating plan Ø MOA: ↓ volume, venous pressure and preload Ø Carvedilol is both alpha/beta
o Fresh fruit/veggies. ↓sodium, ↑ K+, Ø Blacks get better results, associated with ED adrenergic antagonist
↑ Ca; eat fatty cold-water fish 3x/wk. Ø Favorable effect with osteoporosis or osteopenia
Ø Dietary sodium reduction – less than 2.4 g/day Ø High dose 25mg or more - potential for negative impact on
Ø Aerobic physical activity glucose and dyslipidemia – hyperuricemia (gout), hyperglycemia BETA-BLOCKERS – “-OLOL”
o 40 min / 3-4 days per week Ø Monitor Na+, K+, Mg++ depletion, calcium sparing (good for
Ø MOA: block beta1 receptors in heart
Ø Moderation of alcohol osteoporosis due to lower observed fx risk)
Ø Lowers heart rate and stroke volume
o Men < 2 Ø HCTZ (contraindicated with sensitivity to sulfa drugs)
Ø Monitor for worsening asthma, COPD
o Women < 1 Ø DO NOT USE: heart block, bradycardia
Ø USE: MI, migraines, glaucoma, resting
CALCIUM CHANNEL BLOCKERS “-IPINE” tachycardia, angina, hyperthyroidism
ALDOSTERONE ANTAGONIST DIURETICS Ø MOA: Systemic vasodilation, slows HR Ø Whites get better systolic control than
Ø MOA: blocks aldosterone so ↑ elimination of Ø Most potent BP controlling med on the market blacks – 4th line anti-HTN med
Na+ and H20 in kidneys to conserve K+ o DHP (doesn’t hurt pulse) (↓ BP): amlodipine Ø Used more for heart failure and not BP
Ø Used for HTN, CHF, hirsutism, precocious o Non-DHP (↓ HR and BP a little): diltiazem, verapamil Ø Reduces effects of circulating
puberty Ø 1st line choice in African American HTN catecholamines
Ø Adverse effect: Gynecomastia, hyperkalemia Ø Causes headaches, ankle edema, bradycardia, reflex tachycardia
Ø Avoid w/ potassium-sparing diuretics, ACEI or Ø DO NOT USE: heart block, bradycardia, CHF
K+ supplements, renal insufficiency, DM2 w/ Ø Avoid grapefruit, macrolides ACEI “-pril” or ARB “-sartan”
microalbumin Ø Work better at night Ø MOA: Block conversion of angiotensin
Ø Spironolactone (Aldactone) Eplerenone I → II
(Inspra) Ø 1st choice in HTN with DM or renal
DIGOXIN disease
Ø Dry hacking cough, (more w/ACEI),
Ø ECG in therapeutic: prolonged PR, depressed, cupped ST segment
hyperkalemia, angioedema
Ø ECG with toxicity: AV heart block
Ø Adjust dose in renal insufficiency
Ø Patients with toxicity have anorexia
Ø AVOID in pregnancy, renal artery
Ø Drug interactions: amiodarone, diltiazem, macrolides,
stenosis, acute renal insufficiency
antifungals, cyclosporine and verapamil
CARDIOVASCULAR SYSTEM
OVERWEIGHT/OBESITY
DYSLIPIDEMIA NIACIN
Ø Screening and detection Ø BMI – ratio of weight to height ↓ LDL 5-25%
o Lipid profile in those with cardiovascular risk (DM, o Weight (kilograms)/height (meters) ↑ HDL 15-35%
HTN, strong family hx and obesity) o Muscular patients can have falsely ↓ TG 20-50%
o 12 hours fasting elevated BMI Adverse effect: flushing (minimize by taking
§ Total cholesterol (TC) Ø Underweight < 18.5 ASA 1-hour prior), hyperglycemia,
§ Low-density lipoprotein (LDL) Ø Normal 18.5 to 24.9 hyperuricemia, upper GI distress, hepatotoxic
§ High-density lipoprotein (HDL) Ø Overweight BMI 25 to 29.9
§ Triglycerides (TC) Ø Obese BMI > 30
Ø Dietary options to ↓ LDL (5-10%) o Male: waist circumference: >40 inches
o Female: waist circumference: >35 FIBRATES
o Plant sterols – Take Control/Benecol margarine ↓ LDL 5-20%
o Oatmeal, oat bran o Waist-to-hip: 1.0 (males)
↑ HDL 10-20%
Ø Reduce intake of saturated fat and cholesterol o Waist-to-hip: 0.8 (females)
↓ TG 20-50%
o Avoid trans fat Ø Diagnosing metabolic syndrome Can cause ↑ in LDL with high TG
o Total cholesterol < 200 o 3 characteristics: abd. obesity (weight Adverse effect: dyspepsia, gallstones,
Ø Increase omega-2 fatty acids circumference), HTN, hyperlipidemia or myopathy, do not use in severe renal/hepatic
o Fish twice a week Ex: fenofibrate
↑ triglycerides and ↓ HDL (insulin
o Flaxseed, walnut, canola and soybean oils
o If CHD, take 1-gram EPA + DHA (salmon 4oz daily or insensitivity), fasting glucose > 100 or dx
fish oil supplement use) diabetes FISH OIL (OMEGA 3)
4 gram/day
↓ TG 20-30%
STATIN THERAPY Adverse effect: ↑ risk of bleeding, GI upset
High-intensity Moderate-intensity Low-intensity due to fishy taste – freeze capsules, take with
HMG-CoA INHIBITOR (STATIN) food, avoid hot beverages immediately after
Avoid in >80, Preferred if high Not recommended ↓ LDL 18-55%
impaired renal risk for adverse ↑ HDL 5-15%
function, frailty, effects ↓ TG 7-30%
multiple Baseline hepatic enzymes – no further monitoring
comorbidities, with required
SECONDARY HYPERTRIGLYCERIDEMIA
fibrate Avoid grapefruit juice with simvastatin, atorvastatin, Untreated/undertreated hypothyroidism
LDL reduction 50% LDL reduction 30- LDL reduction lovastatin Poorly controlled diabetes
49% <30% Adverse effects: rhabdomyolysis, myositis Excessive alcohol use
Atorvastatin 40-80 Atorvastatin 10-20 Pravastatin 10-20 • Risk factors for myositis (advanced age, low
Rosuvastatin 20-40 Rosuvastatin 5-10 Lovastatin 20 body weight and high-intensity statin therapy)
Simvastatin 20-40 Simvastatin 10 SELECTIVE CHOLESTEROL ABSORPTION
Pravastatin 40-80
Lovastatin 40 INHIBITOR
BILE ACID RESINS ↓ LDL 15-20%
ASCVD – high intensity ↓ LDL 15-30%
LDL > 190 – high intensity ↑ HDL 3-5%
↑ HDL 3-5% Examples: ezetimibe (Zetia)
Diabetes – moderate intensity ↑ TG if > 400
10 yr. ASCVD risk > 7.5% - moderate to high intensity Generally used as add-on (Vytorin)
Examples: cholestyramine, colestipol, colesevelam
**Not enough data of benefit > 75 Adverse effects: constipation, ↓ absorption of other
Take at night with baby ASA meds
CARDIOVASCULAR SYSTEM
Digitalis toxicity,
Paroxysmal Abrupt onset of palpitations, rapid pulse, Vagal maneuvers, carotid massage, ice May be seen in Wolf
alcohol,
Supraventricular lightheadedness, shortness of breath and anxiety EKG water to face. If WPW or symptomatic call Parkinson White
Hyperthyroidism,
Tachycardia (PSVT) HR range from 150-250bpm 911 Syndrome
caffeine, illegal drugs
CARDIOVASCULAR
CARDIOVASCULAR
HEART BLOCK
Ø First Degree AV Block: prolonged PR>0.2 seconds
o If the R is far from P – FIRST DEGREE
Ø Second Degree Type I (Wenckebach): PR is progressively longer
until it drops
o Longer, Longer, Longer, drop then you have
WENCKEBACH
Ø Second Degree Type II: PR constant but drops QRS periodically
o If a QRS don’t get through, then you have MOBITZ II
Ø Third Degree: complete, no pattern between PR and QRS
o If Ps and Qs don’t agree, then you have THIRD DEGREE
PULMONARY SYSTEM
PNEUMONIA - CURB 65 RANDOM PEARLS
Confusion of new onset Ø Pneumonia causes increased right
Blood Urea nitrogen > 19 PHYSICAL EXAM FINDINGS sided heart workload which can be a
Ø Normal chest percussion sound: resonance heart failure trigger in the older
Respiratory rate > 30 adult
Ø Lower lobes: vesicular breath sounds & upper lobes: bronchial
Blood pressure diastolic < 90 or systolic < 60 Ø Consolidation
Age 65 or older o Dullness to percussion
CLASSIFICATION
o Increased tactile fremitus (have pt. say 99)
CURB-65 Results: o Bronchial or tubular breath sounds, often with late Ø Intermittent Asthma (FEV1 > 80% P)
0-1: treat as outpatient inspiratory crackles that do not clear with cough o Symptoms < 2 days week
2: consider short stay in hospital or watch very closely as o Egophony: “eee” sounds like ah Ø Mild (FEV1>80% Predicted)
outpatient Ø Pleural inflammation o Symptoms > 2 days week,
3-5: Requires hospitalization with consideration as to o Sharp, localized pain, worse with deep breath, but not daily
whether patient needs to be in the intensive care unit. movement, cough o Night time 3-4/month
o Audible pleural friction rub (sounds similar to stepping o Minor limitation
in fresh snow) – heard on inspiration & expiration Ø Moderate (most common) 60-80%P
ASTHMA/COPD Ø Air trapping o Symptoms daily
o Hyperresonance o Night time > 1x week
COPD ASTHMA
o ↓ tactile fremitus o Some limitation
LAMA LABA ICS Ø Severe (FEV1<60% Predicted)
-ium & terol one o Wheeze (exp. first, insp. later)
o Low diaphragms o Symptoms throughout day
glycopyrrolate ide o Night time often 7x week
SABA (beta2 agonist) o ↑ AP diameter
o Extreme limitation
How often? 1-2x/wk.
More often (add)
INHALED CORTICOSTEROIDS (ICS)
Less often (drop)
Ø Preferred controller tx for persistent asthma STEP WISE
Ø Requires constant daily use for optimal effect Ø Intermittent Asthma
INHALED MUSCARINIC ANTAGONIST Low dose Medium High dose o SABA
Ø Emerging role in asthma dose Ø Step 2
Ø Well established in COPD (offer protracted duration) Beclomethasone 80-240mcg >240- >480mcg o Low dose ICS
Ø Used for prevention, not treatment (use scheduled) (QVAR) 480mcg Ø Step 3
o SAMA - Ipratropium bromide (Atrovent) Budesonide 180- >540- >1080mcg o Low dose ICS + LABA or
§ bronchodilation (Pulmicort) 540mcg 1080mcg o Medium dose ICS
o LAMA - Tiotropium bromide (Spiriva); Fluticasone (Flovent) 88-264mcg 264-440mcg >440mcg Ø Step 4
umeclidinium (Ellipta) Mometasone 100- 300-500mcg >500mcg o Medium dose ICS + LABA
Ø Anticholinergic – can contribute to worsening BPH (Asmanex) 300mcg and consider omalizumab
o If occurs switch from LAMA to LABA such as for allergies
salmeterol Ø Step 5
INHALED CORTICOSTEROIDS/LONG ACTING BETA2 AGONIST (ICS/LABA) o High dose ICS + LABA + oral
Ø Preferred controller tx for moderate to severe persistent corticosteroid and consider
asthma omalizumab for allergies
LEUKOTRIENE MODIFIER
Ø BLACK BOX: ↑death in asthma patients using LABA
Ø Additional benefit with allergic rhinitis, most often in Ø Requires consistent, daily use for optimal effect
conjunction with ICS o Budesonide + formoterol (Symbicort) PDE-4 INHIBITOR
Ø Requires consistent daily use for optimal effect o Fluticasone + salmeterol (Advair) Ø Roflumilast (can induce psychosis)
o Montelukast (Singular) o Mometasone + formoterol (Dulera) Ø Minimizes risk of COPD exacerbation
COPD: FEV1/FVC < 70 PULMONARY SYSTEM
Ø Dramatically increases right sided heart workload
Hx of A fib, estrogen
therapy, smoking, Sudden onset dyspnea and coughing. Cough
surgery, cancer, may be productive of pink-tinged frothy
Pulmonary Emboli
pregnancy, long bone sputum. Tachycardia, pallor and feelings of
fractures and prolonged impending doom
inactivity
Impending Tachypnea, tachycardia or bradycardia,
Cyanosis and quiet lungs. Epi stat. 911 oxygen, albuterol nebs,
Respiratory Failure cyanosis and anxiety. Patient appears
May speak in 1-2-word parenteral steroids, antihistamines and H2
- Asthmatic exhausted, fatigued, diaphoretic and uses
sentences blocker
Exacerbation accessory muscles to help with breathing.
High risk: > 2
exacerbations in last year,
FEV1 < 50%, hospitalized
Chronic cough (2 years), chronic sputum Smoking cessation, pneumonia & flu vaccine,
for COPD in past year
production, shortness of breath worse with Acute exacerbation: SABA, LABA, ICS
Spirometry FEV1/FVC **rarely see under age 40
physical exertion, progressive symptoms, Acute prednisone 40mg/day x 5-10 days
Alveolar damage from <0.70 post- Chronic bronchitis:
COPD – barrel chest, weight loss; hyperresonance upon **↑ dyspnea, ↑ sputum volume & purulence
loss of elastic recoil of bronchodilation. cough with excessive
can include chronic percussion, tactile fremitus and egophony is may need antibiotic; higher risk for Strep
lungs, exposure of Classification of severity mucous for 3+ months
bronchitis and decreased; CXR may show hyperinflation; pneumonia & H. influenzae –Augmentin
irritants determined by FEV1 for 2+ years
emphysema bullae sometimes present; coarse crackles (avoid due to GI upset) Cefdinir, macrolide
Airflow limitation CXR only when trying to
Alpha-1 antitrypsin deficiency screening (avoid due to CV risk); resp. fluoroquinolone
R/O pneumonia Complex patients with
< 45yrs (↑ tendon rupture)
co-morbidities:
** pack year smoker – COPD**
Multiple meds, drug-
drug interactions, drug-
disease interactions
Strep pneumoniae; S. pneumoniae: macrolides, doxycycline, Flu vaccine > 50yo
Sudden onset high fever w/ chills, productive Chest x-ray-lobar
H. influenzae; DRSP: high dose amoxicillin, resp. Pneumo vaccine >65yo
cough and purulent sputum (rust-colored if consolidation (note: middle
Mycoplasma; fluoroquinolones. Smokers – H.
Community- strep pneumo). c/o pleuritic chest pain w/ lobe is anterior chest by
Chlamydophila Minimum 5 days (most 5-7 days) Influenza
Acquired coughing and dyspnea nipple)
pneumonia; No comorbidities: Macrolides, S. pneumoniae affects
Pneumonia (CAP) Rhonchi, crackles or wheezing with dullness CBC: leukocytosis (>10.5)
Cystic fibrosis: doxycycline young and old
over affected lobe, ↑ tactile fremitus and look for anemia
Pseudomas aeruginosa Comorbidities: resp. fluoroquinolones, or Lung cancer can present
egophony; abnormal whispered pectoriloquy
(Gm-) macrolide plus beta-lactam as recurrent pneumonia
Fatigue w/ paroxysmal coughing that’s
Mycoplasma;
nonproductive; gradual onset starting like a ***Legionella –
Chlamydophila
Atypical cold; most continue to work/school regardless Physical, chest x-ray shows Macrolides, resp. fluoroquinolones, contaminated by inhaling
pneumonia;
Pneumonia of symptoms diffuse infiltrates, CBC doxycycline; antitussives, fluids/rest mist from a water source.
Legionella
Wheezing with diffuse crackles/rhonchi, Also accompanied by GI
rhinorrhea, erythematous throat
Sudden onset new cough that’s dry and possible Exacerbation of asthma
Symptomatic: dextromethorphan, Tessalon
Virus causing small amts sputum; frequent paroxysms of Pneumonia from
PERLES, guaifenesin, severe wheezing
Acute bronchitis inflammation of Upper coughing, possible low-grade fever, wheezing History, possible chest x-ray secondary infection
Atrovent or albuterol inhaler consider
respiratory tract and chest pain w/ cough; cough keeping him ***On rare occasion
steroids 40mg for 3-5 days
awake at night macrolide or doxycycline
Nasal swab for culture and
Cough lasting longer than 14d with 1 of 1st line: macrolides
PCR
following: paroxysmal coughing, inspiratory Chemoprophylaxis for close contacts Complications: Sinusitis,
Pertussis Bordetella pertussis Pertussis antibodies by
whooping w/o cause. Can last months. 3 stages: Respiratory precautions OM, pneumonia, fainting,
“whooping cough” bacteria (Gm -) ELISA
catarrhal, paroxysmal, convalescent. Most Antitussives, mucolytics, rest and hydration rib fractures
CBC: lymphocytosis (80%
infectious early in disease Tdap booster > 11yo
lymphocytes in WBC)
PULMONARY SYSTEM
Asthma COPD
X
LUNG CANCER SCREENING
Consider steroid
Ø Symptoms: first for treatment
X
o Chest discomfort, dyspnea, hemoptysis, cough
Anticholinergics are
Ø High risk patients
not usually helpful
o Age 55-74 who smoked at least 30 pack year and/or Disease is X
have quit in last 15 yrs.
progressive
o High risk smokers at age 50
NEVER!! LABA alone is safe X
Ø Current limitations include:
X Steroid alone is
o High false-positive rate safe
o Radiation exposure from multiple CT scans
X Needs rescue X
o Patient anxiety
inhaler
WHEN TO USE INSULIN ENDOCRINE SYSTEM
All Type 1 DM patients
Basal insulin with adjustments for meals DIABETIC MEDICATIONS FOR DM
- Basal 40-50% total daily insulin
Ø Consider what therapeutic goal is? Correction of fasting glucose, postprandial glucose, action on insulin resistance, increasing
- Bolus 50-60% total daily insulin, given in
insulin availability, offloading of glucose? Hypoglycemia risk? Cost? Adverse effects?
response to carb intake post meals and
Ø BIGUANIDE – insulin sensitizer, ↓ hepatic glucose production and intestinal glucose absorption. Action on fasting &
with snacks (2 Units to 15 carbs
postprandial. Minimal to NO hypoglycemia when used alone.
Type 2 DM patients
o Metformin/Glucophage (1500-2000/day prevention)
- At time of diagnosis to achieve initial
§ A1c reduction 1-2%
glycemic control if A1c >9%
§ Contraindicated: eGFR < 45, acidosis, alcoholic, hypoxia, Active liver disease (hep C), heart failure
o Short course 2-3 weeks
• FYI – can use 1000mg daily for GFR 30-45 – don’t start them on it, but can continue
- A1c > 10%
§ ↑ B12 deficiency (after on meds > 5 yrs.) – ok to give in Stage 1 Heart Failure
- When > 2 standard agents are
§ Risk of lactic acidosis (rare)
inadequate
§ Hold if IV contrast dye testing for 48h
- Start 0.1-0.2 u/kg or 10 units
§ Side effects: diarrhea, flatulence and nausea
- Adjust 2-4 u (or 10-15%) 1-2x weekly to
Ø THIAZOLIDINEDIONE (TZD) – insulin sensitizer. Action on fasting & postprandial. Minimal to NO hypoglycemia used alone.
reach FBG goal (80-130 in am)
- If hypoglycemia – decrease by 4 units o Pioglitazone (Actos), Rosiglitazone (Avandia) – monitor ALT
(10-20%) § A1c reduction 0.7%
- If am is reached, but during the day it § Avoid heart disease/CHF, causes edema, rare risk of bladder cancer, liver toxicity, weight gain, fractures
spikes – Ø SULFONYLUREA – stimulates b-cells to secrete insulin – Action on fasting & postprandial. HYPOGLYCEMIA RISK
o Basal Plus: short acting insulin o Glipizide (Glucotrol)**preferred over glyburide in older adult, Glyburide (Diabeta) **long half-life; BEERS criteria
before biggest meal of day avoid, Glimepiride (Amaryl) - cheap
o Basal Bolus: bolus at each meal § A1c reduction 1-2%
§ Acts like basal insulin – constant insulin release (less effective after many years)
§ adjust dose in renal impairment
§ Side effects: weight gain and hypoglycemia
Ø DPP-4 INHIBITOR - ↑ insulin release, largely in response to ↑blood glucose post meal. Action largely on postprandial.
Minimal to NO hypoglycemia, expensive
o A1c reduction 0.6-1.4%
INSULINS o Sitagliptin (Januvia), Saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina) – weight neutral, oral agents
Onset Peak Duration o Pancreatitis risk and unexplained joint aches
Rapid acting 15 min 30 min 4.5 hrs.
Ø MEGLITINIDE – minimize postprandial hyperglycemia; Repaglinide (Prandin) and Nateglinide (Starlix)
(Lispro, – 2.5
Ø GLP-1 AGONIST – ↑ insulin release, largely in response to ↑blood glucose post meal. Action largely on postprandial. Minimal
Aspart) hr.
hypoglycemia, expensive. Injection only.
Short acting 30 min 1-5 6-8 hrs. o A1c reduction 1-1.5%
(Regular) hrs. o Exenatide (Byetta, Bydureon), liraglutide (Victoza), albiglutide (Tanzeum), dulaglutide (Trulicity)
Intermediate 1 hr. 6-14 18-24 o Slows gastric emptying, leading to appetite suppression and possible weight loss
NPH hrs. hrs. o N/V, contraindicated in gastroparesis, rare pancreatitis risk, avoid in severe renal impairment or ESRD
Basal 1 hr. None 24 hrs. Ø SGLT2 INHIBITOR – lower plasma glucose by ↑ amount of glucose excreted in urine. Primarily postprandial effect.
(Lantus Levemir HYPOGLYCEMIA RISK when used with insulin and insulin secretagogues (Sulfonylurea, DPP-4 inhibitor, GLP-1 agonist)
Levemir) usually
o A1c reduction 0.7-1%
BID
o Canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance) – weight loss, lowers BP
Mixture 30 min. 4.4 24 hrs.
70/30 hrs. o ↑ risk GU infection adjust dose in renal impairment, DKA and urosepsis risk
ENDOCRINE SYSTEM
ADDITIONAL DIABETES CONSIDERATIONS ENDOCRINE FACTS
Ø A – Aspirin (81-162 mg daily) in most, esp. men > 50 Ø Endocrine works as negative feedback – low level of active hormone stimulates production.
and women > 60 with DM and > 1 additional CVD Ø Hypothalamus stimulates anterior pituitary gland into producing stimulating hormones (FSH, LH, TSH) – these
risk factor such as HTN, smoking, family hx hormones tell organs to produce hormones.
Ø B – BP controlled > 2 agents including ACEI/ARB and Ø Hypothalamus: coordinates nervous and endocrine system by sending signals, produces neurohormones that
thiazide stimulate or stop production
Ø C – Cholesterol: statin therapy > 40 or hx ACS. Goal Ø Pituitary Gland:
Lipids < 100 Hypothalamus
Creatinine (renal function): serum creatinine, TRH, GnRH, CRH, GHRH, Somatostatin
calculated GFR and urine microalbumin annually “On or Off” Switch
Ø D – Diet: limit trans and saturated fat. Schedule with Released by Anterior Pituitary
dietician if needed TSH, FSH, LH, GH, ACTH, MSH, Prolactin, Vasopressin, and Oxytocin
Dental care: reinforce Target Organs
Ø E – Exercise: > 150 min/week (walking) + resistance Thyroid (TSH): T3 and T4 (thyroxine) – free or bound (no impact on metabolism)
exercise 3x week Ovaries/Testes (FSH/LH): estrogen, progesterone, androgens, testosterone
Eye exam: annually (diabetic retinopathy) Adrenal Cortex (ACTH): glucocorticoids, mineralocorticoids
o Neovascularization (new growth of fragile Body (GH): somatic growth
arterioles in retina), microaneurysms, Uterus (oxytocin): uterine contractions, bonding
cotton wool spots, soft/hard exudates Kidneys (vasopressin): blood volume
Ø F – Foot exam: visually every visit & monofilament Pineal (melatonin): circadian rhythm
at minimum annually Breast (prolactin): milk production
Ø G – Goals of care Ø Posterior pituitary: secretes antidiuretic hormone and oxytocin which are made by hypothalamus and stored
and secreted by posterior pituitary
Ø Thyroid gland: uses iodine to produce T3 (huge impact on metabolism – 5x) and T4 (small changes affect TSH)
Ø Parathyroid glands: produce PTH which is responsible for calcium balance of body by regulating calcium loss
or gain from bones, kidneys and GI tract
Ø Pineal gland: pea-sized gland in brain that produces melatonin.
SOMOGYI EFFECT
Ø Severe nocturnal hypoglycemia stimulating glucagon to be
released from the liver
Ø High FBG by 7:00a, usually due to overtreatment with
evening or bedtime insulin – more common in Type 1 RANDOM OBESITY PEARLS
Ø Diagnosed by checking glucose at 3am for 1-2 weeks Ø Orlistat – take within an hour of each meal that contains fat
Ø Tx: Snack before bedtime or eliminate/lower bedtime Ø Belviq – avoid with medications that have serotonergic effect
NPH/regular insulin Ø Phentermine – teratogenic effects
Ø Serotonin is responsible for the sensation of satiety
Ø 1 pound of fat contains 3500 calories
DAWN PHENOMENON Ø 10,000 steps is = 4-5 miles
Ø Elevation in FBG daily early in morning from increase in Ø Weight loss meds: if not achieved 5% weight loss by week 12, discontinue therapy
insulin resistance between 4 and 8am caused by spike in GH Ø Weight loss of 10%+ yields immediate reduction in death from cardiovascular and cerebrovascular disease
and glucagon Ø Bariatric surgery- most dramatic weight loss is seen in first few months, calcium absorption will be reduced,
rapid weight loss can contribute to gallstones, lifelong vitamin B12 supplementation is recommended
Ø Obesity can lead to OSA, steatohepatitis, female infertility and endometrial cancer
ENDOCRINE SYSTEM
THYROID
HYPOTHYROID HYPERTHYROID
THYROID
SKIN Thick, dry Smooth, silky Ø Thyroid-stimulating hormone (TSH) NL 0.4-4.0 (goal 1.2)
o Evaluates hypothalamic-pituitary function
REFLEXES “hung up” patellar reflex, slow arc Hyperreflexia
§ Anterior pituitary ability to detect circulating
out, slower arc back, overall
free thyroxine
hyporeflexia
o When TSH normal, thyroid disease ruled out
MENTATION “can’t make sense, thoughts too “Can’t make sense, mind
Ø Free T4 (free thyroxine)
slow” racing”
o Unbound, metabolically active portion of thyroxine
WEIGHT CHANGE Small gain 5-10 lbs. Loss ~ 10 lbs.
o F/U test to confirm, support dx of hypo or
STOOL PATTERN Constipation Frequent, low volume,
hyperthyroidism with abnormal TSH
loose
Ø Thyroid peroxidase antibody (TPO Ab)
MENSTRUAL ISSUE Menorrhagia Oligomenorrhea o Test to help detect autoimmune thyroid disease
HEAT/COLD INTOLERANCE Easily chilled Heat intolerance o Measures antibody against peroxidase
OTHER Hypertriglyceridemia Proximal muscle weakness Ø Total T4 (total thyroxine)
Tachycardia, HTN o Reflects the total of the protein-bound and free
thyroxine
o (useless – altered with medications, clinical conditions)
LFT’S
Ø Aspartate Aminotransferase – (AST) (SGOT) present in liver, heart, muscle, kidney and lung
Ø Alanine Aminotransferase – (ALT) (SGPT) found mainly in liver; + liver inflammation – more specific
for hepatic inflammation
o If both AST and ALT elevated
§ ALT > AST – (liver) think hepatitis
§ AST > ALT - (Acetaminophen, Statins, Tequila)
Ø AST/ALT Ratio
Ø McBurney’s point – Area between superior iliac o 2.0+ = alcohol abuse
crest and umbilicus in RLQ o 1-2 = ETOH, liver disease
o <1 = fatty liver disease
Ø Serum GGT – elevated in liver abuse and acute pancreatitis; sensitive for alcohol abuse
Ø Alkaline Phosphatase – (ALP) enzyme derived from bone, liver, gallbladder, kidneys, GI and
placenta. ↑ levels seen during growth spurts; healing fractures, osteomalacia, bone malignancy,
vitamin d deficiency, Paget’s, bone cancer
o Expect elevation in pregnancy and kids
Ø Albumin – liver makes albumin
Ø
GASTROINTESTINAL SYSTEM
Acute onset periumbilical pain steadily CT with contrast Peak age 10-30
worsening over 12-24h. Pain localizes at **Abd US can be used in myelocytes/metamyelocytes
Inflammatory disease
McBurney’s point with rebound and guarding, (immature neutrophils) –
Acute Appendicitis caused by infection or younger thinner people REFER
anorexia. Psoas and obturator signs + ominous marker in life-
obstruction Left shift: ↑ WBC, ↑
If ruptures, have guarding, rebound, and board threatening infection found
neutrophils, ↑ Bands
like abdomen. in appendiceal rupture
Severe RUQ or epigastric pain constant with 2- Risk factors: fair, fat, 40
Inflammation of 3 minutes of increased pain (colicky pain) can Cholelithiasis – stones, no
Elevated AST, ALT and ALP Gut rest with clear liquids
Acute Cholecystitis gallbladder nearly always occur w/in 1h of consuming fatty meals. Pain inflammation
RUQ abdominal US - HIDA REFER to Surgery
caused by gallstones can radiate to right shoulder, N/V, anorexia, Collins – pain radiating to
intermittent fever, + Murphy’s sign right shoulder
Risk factors: ↑ age,
constipation, low dietary
Fever, anorexia, nausea, cramping, LLQ pain. Ciprofloxacin + Metronidazole 10-14d
CBC shows leukocytosis w/ fiber intake, obesity, lack of
Infected diverticula - Blumberg’s sign; Acute abdomen rebound, or
neutrophilia Bands signal exercise, NSAIDs, family
Acute (diverticulosis most Rovsing +, board like abdomen. Levaquin + Flagyl
severe bacterial infection; hx, connective tissue
Diverticulitis common in sigmoid Diverticulosis – exam normal High fiber diet
FOBT + if bleeding disorder, Complications:
colon) 33% of population will develop diverticulosis Follow-up in 48-72h
CT scan definitive scan Sepsis, Ileus, SBO,
by age 50 If worsens refer to ER
hemorrhage, perforation,
fistula, death
Acute onset fever, N/V associated with rapid ↑ serum amylase, lipase and Ileus, sepsis, shock, multi-
onset severe abdominal pain radiating to trypsin; ↑ AST and ALT, organ failure
Drug use, Alcohol abuse,
mid-back with bloating. Guarding and GGT, bilirubin, leukocytosis; **Risk factors for
Acute Pancreatitis gallstones, elevated REFER
tenderness over epigastric region on exam. + abdominal ultrasound and pancreatic CA include
triglycerides, infections
Cullen’s sign and Grey-Turner’s sign **rocks CT chronic pancreatitis,
back and forth to relieve pain Triglycerides > 800 ↑ risk tobacco use, DM
Severe watery diarrhea 10-15 stools a day w/
Clostridium lower abdominal pain, cramping and fever. CBC w/ leukocytosis Metronidazole (Flagyl), avoid
difficile Colitis Symptoms appear 5-10d after antibiotic (>15,000) antimotility agents and opiates,
(C-diff) initiation (clindamycin, quinolones, Stool assay for C-diff increase fluid intake
cephalosporins and PCNs)
Colonoscopy age 50 (repeat Screen everyone with these questions: ↑ risk factors >50 yrs.;
Asymptomatic until advanced disease. Vague
every 10 yrs. unless polyps) Have you ever had colorectal cancer multiple polyps or
adenocarcinomas GI symptoms, changes in bowel habits, stool or
<40 assess cancer risk; FOBT (CRC) or adenomatous polyp (AP)? inflammatory bowel disease
Colon Cancer 3rd leading cause of bloody stool. Heme-positive stool, dark tarry
annually ever year; Inflammatory bowel disease? Family (diet in high fat, red meat
cancer deaths in US stool, mass on abdominal palpation. May have
Cologuard every 3 yrs. member with CRC or AP? and low calcium may
hx of polyps
If CRC - Surgery, chemo and radiation contribute
fever, malaise and mild weight loss,
↑ CRP, ESR, Leukocytosis ↑ risk of toxic megacolon
Inflammatory bowel periumbilical to RLQ pain. May palpate tender Lactulose intolerance is common. Stop
Anemia (chronic disease, B12 and colon cancer; risk of
disease affecting mouth abdominal mass. Remission and relapses are smoking. Gut rest. Oral
deficiency) development of lymphoma
Crohn’s Disease to anus common. If ileum involved, diarrhea without aminosalicylates sulfasalazine and
WBCs in stool especially when treated
(Inflammation affects blood or mucous. If colon involved bloody mesalamine (better tolerated). Flagyl
Cobblestone mucosal pattern with azathioprine. More
entire intestine wall) diarrhea with mucus. Fistula formation and and Cipro. Immune modulators
on endoscopy – skin lesions common in Jews
anal disease.
bloody diarrhea with mucus. Severe
“squeezing” cramping pain located on left side
Inflammatory disease of abdomen with bloating and gas exacerbated ↑ CRP, ESR, Leukocytosis Oral aminosalicylates sulfasalazine and
affecting colon/rectum by food. Relapses characterized by fever, Anemia mesalamine (better tolerated) ↑ risk of toxic megacolon
Ulcerative Colitis
(Inflammation affects anorexia, weight loss and fatigue. Accompanied WBCs in stool Corticosteroids. No antibiotics due to and colon cancer
mucosa) by arthralgias and arthritis that affects large risk of C. Diff. Immune modulators
joints, sacrum and ankylosing spondylitis. May
have IDA or anemia of chronic disease
GASTROINTESTINAL SYSTEM
CEREBELLAR SYSTEM CEREBELLAR TESTING CRANIAL NERVES
Ø Romberg Test – stand Coordination (Diadochokinesia) ** Some Say Marry Money But My
with arms/hands straight Ø Rapid alternative movement: Brother Says Big Brains Matter More
on each side and with feet patient to place lower arms on top (Sensory, Motor, Both)
together. Have eyes of each thigh and move them I (S) – Olfactory smell (one nose)
closed; Positive if alternating between supination II (S) – Optic visual acuity, visual field,
excessive swaying or and pronation positions fundoscopy (2 eyes)
imbalance Ø Heel-to-shin testing: patient in III (M) – Oculomotor
(Proprioception) supine position with extended upward/medial/downward
Ø Tandem test – have pt. legs. Patient to place the left heel movements of eye (need CN 3 to look
walk straight line in on the right knee and then move it up)
normal gait. Instruct to down the shin – repeat w/ right IV (M) – Trochlear eyes down and in
walk in straight line with heel on left leg V (B) – Trigeminal touch forehead and 3 MINUTE NEURO EXAM:
one foot in front of the Sensory cheeks clench teeth - Stand with eyes closed: Romberg
other. Positive if loose Ø Vibration, Sharp-dull touch, VI (M) – Abducens eyes look side to - With eyes open: Tandem gait
balance, falling, or unable temperature side - Walk on tip toes (power test of
to walk straight Stereognosis – recognizes familiar VII (B) – Facial crease forehead, close plantar flexion)
object w/ sense of touch eyes tight, puff out cheeks and smile - Walk on heels (power test of
Graphesthesia – identify figures real big dorsiflexion)
NEUROLOGICAL MANEUVERS “written” on skin VIII (S)– Vestibulocochlear/Acoustic, - With eyes closed Pronator Drift
Ø Kernig’s sign – flex pt. Motor hearing, equilibrium (2 ears sitting on followed by finger to nose test
hips one at a time, Ø Gait – observe normal gait; check top of each other, Rinne and Weber) - With eyes open: play the piano
attempt to straighten leg leg muscles for atrophy IX (B) – Glossopharyngeal speech (gag (pyramidal function)
while keeping hip flexed Ø Pronator drift test – stretch out reflex) - Rapid taping or alternative
at 90° arms w/ palms facing up, eyes X (B) – Vagus digestion, defecation, movements
Ø Brudzinski’s sign – closed. Observe for 5-10 seconds slowed heart rate (need CN10 to stick - Close eyes tightly (CN VII)
passively flex/bend for drifting of arms. out tongue) - Open eyes – observe pupillary
patient’s neck toward Ø Reflexes – XI (M) – Accessory Spinal shoulder reflex (CN II, III)
chest. Positive if patient o Quads (Knee-jerk) shrug - Smile (CN VII)
flexes hip and knee to o Achilles (ankle-jerk) XII (M) – Hypoglossal stick out their - Stick out tongue (CN XII)
relive pressure and pain o Plantar (Babinski) tongue - Rapid tongue movements
Ø Nuchal rigidity – tell (pseudobulbar palsy)
patient to touch chest - Visual fields by confrontation (CN II)
with chin. Inability to CRANIAL NERVE TRICKS - Eye movements (CN III, IV & VI)
touch chest secondary to Ø Cranial nerves responsible for extraocular eye movements? - Babinski
pain is positive. o 3, 4, 6 – make the eyes do tricks - Fundoscopy
NERVOUS SYSTEM
MIGRAINES
Headache Symptoms Aggravating Factors
Acute Treatment Prophylaxis
Migraine without aura Throbbing pain behind one Red wine, MSG, aspartame, Ice pack on forehead, rest in TCAs
eye, photophobia, N/V menstruation, stress dark quiet room Episodic migraine (<14 days
phonophobia, last 4-72 hr. Triptans, Tigan suppositories per month)
Migraine with aura Preceding symptoms plus
Foods high in triptans. Beta-blockers
scotoma, lights, halos, Teenage to middle-age
last 4-72 hr. females
Trigeminal neuralgia (CN V) Intense and very brief, sharp Cold food, cold air, talking, Carbamazepine (Tegretol) or Tegretol or Dilantin
stabbing pain, one cheek touch, chewing, older adults phenytoin (Dilantin) Watch for drug interactions
and elderly Check serum levels
Cluster Severe “ice-pick” piercing pain Occurs at same time daily in 100% oxygen at 12 LPM May become suicidal
behind one eye and temple; clusters for week
to months; Intranasal 4% lidocaine Spontaneous resolution
with tearing, rhinorrhea, middle aged males
ptosis and miosis on one side ETOH can trigger
(Horner’s syndrome)
Temporal arteritis (giant cell Unilateral pain, temporal area polymyalgia
Medical urgency; Refer to ED or Permanent blindness;
arteritis) with scalp tenderness, skin rheumatica (up to 50%); older ophthalmologist temporal artery biopsy is gold
over artery is indurated,
adults and elderly Lab: ESR standard
tender, warm and reddened; High dose steroids
amaurosis fugax (temporary
blindness)
Muscle tension Bilateral “band-like” pain, Stress NSAIDs, Tylenol, hot Stress reduction, yoga,
continuous dull pain, may last Adults bath/shower, massage, etc. massage, biofeedback
all day; may be accompanied
by spasm of trapezius muscle
BRAIN DAMAGE:
HEADACHES Ø Apraxia: difficulty performing purposeful movements
PRIMARY SECONDARY
Ø Broca’s aphasia: “nonfluent aphasia” Pt comprehends speech and can read, but has difficulty with
Not associated Associated with motor aspect of speech – word salad
with any other or caused by Ø Wernicke’s aphasia: “fluent aphasia” Pt has difficulty with comprehension but has no problem with
diseases other conditions speaking. Reading and writing can be impaired.
Migraine, Tumor, Ø Frontal lobe damage: (intelligence, personality) dementia, memory loss, difficulty to learn
tension-type, intracranial
cluster bleeding, ↑ICP,
meds like NTG,
meningitis, giant HEADACHE EVALUATION: MINI-MENTAL STATE EXAM (MMSE):
**more common cell arteritis Ø History - Orientation
o Where does it hurt? - Short term memory - Recite 3
Red Flag Headaches:
o Characteristics? unrelated words
Systemic symptoms: o Patient appearance (lights out, fetal position vs - Attention and calculation
- Fever, unintended weight loss reading iPad) Spell “world” backwards or
- Secondary HA Risk factors: HIV, malignancy, o Duration subtract 7 starting at 100
pregnancy, anticoagulation, HTN o Associated symptoms - Recall – ask to repeat the words
Neurological signs, symptoms: Ø Exam – physical including
fundoscopic and neuro exam - Write sentence
- Newly acquired symptoms, confusion, impaired o BP, pulse - Copy design
alertness or consciousness, nuchal rigidity, HTN, o Palpate head,
neck, shoulders, spine - While speaking, look for aphasia
papilledema, CN dysfunction o Bruits (impairment in language
o Acceptable abnormalities include Ø If you are 35+ and develop a new headache – you bought resulting in difficulty speaking)
Photophobia & phonophobia an expensive test
- Unequal pupil size Ø notes should reflect:
If ordering imaging
o Red flag headache HEADACHE DIFFERENTIAL:
Onset: sudden, abrupt or split-second “thunderclap”
headache (subarachnoid) onset with exertion, sex, o Change in pattern, frequency or severity of HA - Nasal stuffiness: sinusitis
o Worsening of HA despite therapy - Jaw claudication, fever, visual
cough ↑ICP
o Unexplained neuro symptoms loss, pain in temple: temporal
Older >50 or < 5 years
o Headache always on the same side arteritis***
Previous headache history - Visual field defect: Optic pathway
o Onset of HA with exertion, cough, intercourse
- Less worrisome if have had HA before lesion (pituitary tumor)
o New onset > 50 yrs.
- “worst headache of my life” – r/o subarachnoid - Blurred vision on bending head:
o HA associated with fever, stiff neck, papilledema,
cognitive impairment or personality change intracranial lesion
Rule-Out: - Headache with N/V: tumor
- Subarachnoid or acute subdural Unilateral vision loss: optic
-
- Leaking aneurysm MINI COG: neuritis
- Bacterial meningitis Ø Three-word recognition
- Sweating, tachycardia:
- Increased ICP Ø Clock drawing (normal or abnormal) pheochromocytoma
- Brain abscess or tumor Ø Three-word recall - Transient visual changes:
Ø Dementia if score 0-2. No dementia if >3 pseudotumor cerebrii***
Ø
NERVOUS SYSTEM
Mean age dx 72
Acute onset headache located on one temple,
Refer to ophthalmologist or ED Permanent blindness
usually in older adult; induration, redness,
Biopsy is definitive test ***women more likely
Temporal arteritis Autoimmune vasculitis cordlike temporal artery accompanied w/ scalp Elevated ESR
High-dose steroids 40-60mg daily (Add than men
(Giant cell arteritis) of temporal artery tenderness. Abrupt visual changes and/or Elevated CRP
PPI to prevent ulcer and possibly Pt’s with polymyalgia
transient blindness (amaurosis fugax). Some
bisphosphonate for bone health) rheumatica are at very
people may also complain of jaw pain.
high risk 30%
Embolic: Acute onset stuttering/speech changes, 911 – Assess ABCs
Blacks, Hispanics and
Embolic or one-sided facial weakness, hemiparesis Risk factors – A fib and HTN; aneurysm,
Stroke (CVA) Indians have ↑
hemorrhagic Hemorrhagic: May have poorly controlled HTN anticoagulants, stimulants, sickle cell,
prevalence
and severe headache, N/V, and nuchal rigidity diabetes, oral contraception, smoking.
Basilar or
Focal neurological finding with stroke-like s/s.
hemiplegic Avoid estrogen agents
resembles TIA.
migraine
Overuse of abortive
Daily headaches w/ irritability, depression and Discontinue medicines or gradually taper
Rebound headache medicines, NSAIDS,
insomnia off
aspirin, narcotics
Immune mediated,
Young adult with abnormal limb sensation, visual
inflammatory,
Multiple Sclerosis loss, motor symptoms, diplopia, gait disturbance, MRI Refer to neurology
demyelinating disease
acute motor symptoms
of CNS
Normal or abnormal
cognition?
Dementia, delirium or Declining cognitive function need safety
depression? assessments:
Insidious; decline in complex attention, executive MMSE: <24 suggestive • Driving
function, learning memory, perceptual motor, dementia
• Financial capacity Most common cause is
social cognition. Medications that impair
Dementia Decline in cognition • Wandering Alzheimer disease
Cognitive deficits must be severe enough to cognition: analgesic,
• Living alone followed by Lewy bodies.
interfere with function and independence anticholinergic, psychotropic,
sedative-hypnotics Caregiver burnout, polypharmacy, family
CBC, CMP, B12, folate, conflict over decision making, risk of
TSH, UA, RPR, HIV, CT injury, elder abuse
and/or MRI
Screen for depression
Sundowning – occurs in
Prescription meds,
delirium and dementia.
substance abuse, drug-
Starting at dusk, the
drug interaction,
Reversible, temporary process. Duration is usually patient becomes agitated,
abrupt drug
brief (hours to days). Pt may be excitable, Remove and or treat illness, infection or confused and combative
Delirium withdrawal, preexisting
irritable, combative, short attention span, metabolic derangement and symptoms resolve in
medical condition,
memory loss and disorientation. the morning. Avoid dark,
infections, electrolyte
quiet spaces. Use radio,
imbalance, heart
do not move furniture or
failure, renal failure
décor.
HEMATOLOGICAL SYSTEM
HOW BLOOD CELLS MADE
Ø RBC, WBC, Platelets come from Stem cell
Ø Infection HEMOGRAM EVALUATION IN ANEMIA MICROCYTIC ANEMIAS
o Bacterial or allergic Ø What are hematocrit, hemoglobin, and RBC values? Ø Low MCV; Low MCHC
§ Neutrophil - infection o Normally hemoglobin to hematocrit ratio 1:3 o Thalassemia
§ Eosinophil – allergic reaction o Iron-deficiency
§ 10 = 30%
§ Lead poisoning
§ Basophil - anaphylaxis § 12 = 36% o Anemia of chronic disease
o Viral § 15 = 45%
§ Lymphocyte o Severe dehydration causes elevated MACROCYTIC ANEMIAS
o Tissue damage Ø Low H/H; High MCV
hematocrit
§ Monocyte o B12 deficiency
o Testosterone = more RBC (hence male have
o Folic acid deficiency
Ø When poly/lymph close = viral higher hematocrit values) § Impaired liver
Ø When poly/lymph far = bacterial Ø What is the RBC size? § Thyroid hypo-function
Ø Pt should look like labs. o RBC size is same size during life § Reticulocytosis
o MCV (cytic = size)
§ Microcytic <80 Ø Drug induced Macrocytosis without
anemia
§ Normocytic 80-96
HOW BLOOD CELLS MADE
ANEMIA o (ETOH >5 drinks in men > 3 drinks
§ Macrocytic > 96 in women; carbamazepine, valproic
Ø RBC, WBC,ofPlatelets
Complex signs andcome from Stem cell
symptoms
o In evolving microcytic anemia acid, phenytoin; malabsorption,
Ø Infection
o ↓RBC, ↓ hemoglobin, ↓hematocrit
§ As MCV ↓ RDW ↑ zidovudine (reversible, but meds
Ø Acute Bacterial
o blood or allergic in primary care)
loss (uncommon outweigh the risks – DC ETOH –
o In evolving macrocytic anemia
Ø Chronic blood loss (common -ininfection
§ Neutrophil primary care) heavy alcohol intake has swollen
§ As MCV ↑ RDW ↑
o Erosive Eosinophil
§ gastritis, – allergic reaction
menorrhagia, GI malignancy cells) Hgb, Hct, RBC, MCHC, RDW)
Ø What is the RBC hemoglobin content?
§
o Leads to IDA Basophil - anaphylaxis normal with ↑ MCV
o MCH or MCHC (chromic = color)
o Viral
Ø Reduced RBC production (sick bone marrow)
o Normochromic: 31-37
o Vitamin Lymphocyte
§ B12, folic acid, iron deficiency, anemia
o Hypochromic: <31 LABS
o Tissue damage
of chronic disease, bone marrow suppression,
Ø What is RDW (RBC distribution width)? Ø Serum iron – measure of iron in circulation
§ Monocyte
reduced erythropoietin production (chronic Ø Serum ferritin – < 15 (iron in storage)
o Index of variation in RBC size
renal failure) – select medications (PPI, o Chronic smokers, COPD, high
o Abnormal = > 0.15 proportion (15%)
metformin) altitudes
§ New cells differ in size
Ø Premature destruction (uncommon) o Hct more than 48% women and
§ Early indicator of evolving microcytic 52% men
o Shortened RBC lifespan (90-120 days normal)
or macrocytic anemia o Hbg more than 16.5 women and
o Sickle cell anemia, thalassemia, hemolytic
Ø What is reticulocyte percentage? 18.5 men
G6PD deficiency Ø Reticulocyte count – indicates ability of
o Body attempts to correct anemia
Ø In a person with normal bone marrow production, bone marrow to produce RBCs
o Normal 1-2%
supplementing the deficient substance will cause H/H Ø TIBC – total iron binding capacity
o Response to anemia is >2%
to increase in 1-2 weeks and normalize within 4-8 o TIBC is ↑ when iron ↓
o Reticulocytopenia - Low means body cannot
weeks o TIBC is ↓ when iron ↑
fix the anemia Ø High Altitude stress – low barometric
pressure causes reduction in arterial PO2
HERBAL MEDICATIONS WITH INCREASED BLEEDING RISK HEMATOLOGICAL SYSTEM
HEMOGLOBIN
Ø Ginseng
Ø Electrophoresis gold standard
Ø Gingko
RBC TESTING o Sickle cell anemia
Ø Fish oil
Hemoglobin 14-18 (males) o Thalassemia
12-16 (females) Ø Secondary polycythemia
Hematocrit 40-50% (males) o Chronic smokers, COPD, high
EFFECT ON H/H altitudes
36-45% (females)
MCV (average size of RBC) o Hct more than 48% women and
COPD ↑ 52% men
< 80 microcytic
Chronic kidney disease ↓ 80-100 normocytic o Hbg more than 16.5 women and
Hypertension N/A > 100 macrocytic 18.5 men
DM with A1c 13.8 ↓ MCHC (average color of RBC) Ø High Altitude stress – low barometric
(↓ IDA, thalassemia) pressure causes reduction in arterial PO2
Aspirin use N/A o CAD, CHF, sickle cell ↑ risk
31-37 normochromic
Testosterone use ↑ MCH (indirect measure of color) complications
Resident of Denver, CO ↑ (↓ IDA, thalassemia)
84 years old ↓ 25-35
If someone comes up
↓ Hgb positive screen the family
Majority asymptomatic. Discovered due to Diagnostic test: Hemoglobin
↓ Hct At risk ethnic groups
abnormal CBC results revealing electrophoresis
↑ RBC Alpha thalassemia:
microcytic/hypochromic RBCs Beta-thalassemia (abnormal) IDA, normal
Genetic producing ↓ MCV Asian, African ancestry
Thalassemia Minor (Blood smear: microcytosis, anisocytosis,
abnormal Hgb ↓ MCHC (AAA)
***Cooley’s anemia is Beta Thalassemia Major – poikilocytosis)
Normal RDW Beta thalassemia:
transfusion dependent anemia (found early in Do not treat thalassemia
Normal to ↑ ferritin and iron African, Mediterranean,
infancy) Genetic counseling prior to pregnancy
Normal TIBC Middle Eastern
(more common in US)
Destruction of stem CBC w/ diff
Bone marrow production slows or stops Pancytopenia
cells inside bone Platelet county
Aplastic Anemia Fatigue, weakness, pale color, tachycardia and Refer to hematologist (leukopenia, anemia,
marrow (radiation, Bone marrow biopsy (gold
systolic murmur; neutropenia, thrombocytopenia thrombocytopenia)
drug, viral infection) standard)
Vitamin B12 deficiency
(pernicious anemia,
B12/folate levels; B12 levels Dietary deficiency may > 5 years to occur gastric disease, infections,
may be normal in 5% of B12 sources: foods of animal origin (meat, antacids and metformin)
Autoimmune causing patients with B12 deficiency poultry, eggs, milk, cheese) Nerve damage from
destruction of parietal Gradual onset of paresthesia on feet/hands, Antiparietal and anti-intrinsic B12 via injections or nasal spray (1000mcg chronic B12 deficiency
Pernicious anemia cells; gastrectomy, pallor, glossitis; numbness/tingling extremities, factor (IF) antibody test + per week for 4 weeks then monthly for a ↑ incidence in older
vegans, alcoholics, neuropathy, diff fine motor skills 24h urine for methylmalonic lifetime) women
bowel disease acid, homocysteine level Oral 1000-2000mg daily 2-3x ↑ gastric cancer
elevated, peripheral blood Multivitamin with iron since IDA **All dementia or
smear (macrocytosis) commonly coexist patients with
neuropathy need B12
levels checked
Elderly, infants,
alcoholics, overcooked
Body’s supply last 2-3 months vegetables, low citrus
Macrocytic normochromic,
Inadequate dietary Anemia, tired, fatigue, pallor, reddened sore Lifestyle changes (dietary – leafy green intake, malabsorption
Folic acid peripheral smear –
intake causing damage tongue, glossitis, unexplained weakness, possible vegetables, grains, beef, liver) (gluten). Drugs that
deficiency macroovalocytes
to DNA or RBCs tachycardia, palpitations, angina or heart failure. PO folic acid 1-5 mg/day interfere: Phenytoin
folate levels <4
Pregnancy 400 mcg daily (Dilantin), sulfa,
metformin, methotrexate,
zidovudine
Refer to hematologist, Sickle cell disease is
Genetic hemolytic Most asymptomatic; extreme anemia, frequent CBC 1 out of 500 African
part of newborn screening; autosomal
anemia; variations in sickling episodes w/ pain, ischemic necrosis of Sickledex – screening Americans in US have
recessive (if each parent trait – one
RBC – sickle shaped bones or skin, renal/liver dysfunction, priapism, Electrophoresis – gold sickle cell anemia
Sickle cell anemia of four will have disease) prenatal
and insufficient of hemolytic episodes, hyposplenism, frequent standard ↑ risk Strep pneumo, H.
screening available as early as 8-10 weeks
oxygen carrying infections – highly susceptible to infection. If Mean Hgb 8.0 influenzae due to
via chorionic villus sampling or
capacity fever give prophylactic PCN up to age 5 RBC live 17 vs. 120 days hyposplenia
amniocentesis
MUSCULOSKELETAL SYSTEM
ORTHOPEDIC MANEUVERS SHOULDER
Ø Drawer Sign – knee instability/torn ligaments Ø Impingement Syndrome – hand at or above level
of shoulder begins to be painful in lateral
shoulder area; reaching into pantry to get can;
reaching up in closet. – Painful Arc Test
Ø McMurray’s test – “click” on manipulation of knee with rotation of ankle; injury to medial meniscus tear
Fracture of distal
Colles Fracture “dinner fork” fracture. Most common type fracture
radius from fall
Hip Pain Location Diagnostic Consideration
Lateral, aggravated by
Sudden onset on-sided hip pain. If mild may be able Trochanteric bursitis More common in
direct pressure
to bear weight. If displaced, inability to walk or bear Pain with use, better with elderly 1-year
Hip Fracture Falls Structural joint problem, OA
weight on affected hip. Severe hip pain with external rest mortality rate from
rotation of the hip/let and leg shortening Constant pain, especially at Infectious, inflammatory, 12-37%
night neoplastic
Depends on degree of injury and structures i.e.:
Anterior hip/groin pain Hip joint: OA, etc.
nerves, blood vessels, organs. Ecchymosis and May cause internal
High-energy trauma Posterior hip pain SI joint, LBP
Pelvic Fracture swelling in lower abdomen, hip, groin, scrotum. hemorrhage - life-
(MVC)
Bladder/fecal incontinence, vaginal/rectal bleeding, threatening
hematuria, numbness.
More common in
RICE – Stop activity for several weeks
Overuse resulting in Recurrent shin pain in one or both legs that runners and those
Medial Tibial Stress Cold packs during acute exacerbation for
microtears and becomes more severe over time. Pain along inner X-ray will not show stress with flat feet.
Syndrome or 20 minutes several times a day
inflammation of border of tibia and occurs during and after exercise. fx. Recommend bone scan Female athlete
Fracture (Shin Use cushioned soles
muscles, bones and Mild swelling and focal area of tenderness painful or MRI triad: amenorrhea,
Splints) Stretch before exercise and start at lower
tendons on palpation may suggest fx eating disorder,
intensity
osteoporosis
Inflammatory
Can develop gradually with symptoms that last for Serum amyloid A; Soluble
condition resulting in
years or have more rapid progression and interleukin 2 receptor; ACE Often self-limiting; NSAIDs;
production of Adults 20-40; women and
resolution of disease. Fever, fatigue, anorexia and Glycoprotein KL-6; Corticosteroids orally, cream, inhaled
Sarcoidosis noncaseating African Americans more
arthralgias, rash, lesions, color change, nodule Hypercalcemia; Hypercalciuria Plaquenil, DMARDs
granulomas common
formation under skin, blurred vision, eye pain, Chest x-ray; CT chest; PFT; Lung transplant
predominately lungs,
severe redness and sensitivity to light biopsy
lymph nodes, eyes, skin
2+, with at least one musculoskeletal:
With diarrhea affects genders NSAIDs, systemic corticosteroids, tumor Often seen days to weeks
asymmetrical oligoarthrtitis, predominately lower
Reactive arthritis equally; with urethritis (male necrosis factor blocker (etanercept or after diarrhea caused by
Acute nonpurulent extremity, sausage shaped finger (dactylitis); toe
(formerly Reiter dominance) with HLA-B27 infliximab); Urethritis treated with Shigella, Salmonella or
arthritis or heel pain; cervicitis, prostatitis, acute diarrhea
Syndrome) positive; culture of joints doxycycline x 7 days or azithromycin Campylobacter or
within one month, conjunctivitis or uveitis, genital
negative single dose Chlamydia
ulceration, urethritis; joint pain knee/ankle/feet
COMMON SSRIS (listed from most to least energizing) PSYCHOSOCIAL MENTAL HEALTH
ANXIETY SYMPTOMS
First line tx for major depression, OCD,
Ø W – Worry
anxiety and premenstrual disorder
DEPRESSION SYMPTOMS Ø A– Anxiety
Ø Fluoxetine (Prozac) longest ½ life
INCREASED RISK OF SUICIDAL THINKING IN THOSE LESS THAN 24 YEARS
ALCOHOL SCREENING SUICIDE ALTERNATIVE MEDS FOR DEPRESSION
Ø C: Do you feel the need to cut down? Ø Males represent nearly 80% of all completed Ø St. John’s wort
Ø A: Are you annoyed when your suicides. o Interacts with SSRI, TCA, MAOI
friends/spouse comment about your Ø Females attempt suicide 2-3 times more often. o ↓ Digoxin effectiveness
drinking? Ø Highest rate of completed suicide is found in o ↓ effectiveness of birth control
Ø G: Do you feel guilty about your drinking? elderly males (75+). Ø 5-HTP, L-tryptophan
Ø E: Do you need to drink early in the Ø Inquiring about suicidal ideation DOES NOT lead o Interacts with SSRI, MAOI,
morning? to suicide. dextromethorphan, Triptans
Ø Positive response to 2/4 is highly Ø Risk Factors: Ø Omega-3 fatty acids
suggestive of alcohol abuse o Older people who have lost a spouse o No major drug interactions
Ø Anyone feeling compelled to drink no o Plan involving gun or lethal weapon o High doses may ↑ risk of bleeding
matter what the consequences is o Hx of attempted suicide o Stop 1 week before surgery
addicted o Mental illness: bipolar, depression Ø Folate and vitamin B6
o Hx of sexual, emotional or physical abuse Ø Exercise, yoga, massage, guided imagery,
o Terminal illness, chronic illness, pain acupuncture, light therapy
ANTIPYSCHOTICS SIDE EFFECTS o Significant loss Ø Kava-Kava and valerian root are both used for
Ø Pill rolling, shuffling gait, bradykinesia o Bipolar is higher risk during depressive anxiety and insomnia. Do not mix with benzos,
Ø Extrapyramidal symptoms: episode hypnotics or any CNS depressants
o Akinesia - inability to initiate Ø 3 important questions:
movement o Are you thinking of hurting yourself?
o Akathisia - strong inner feeling to o If yes, do you have a plan?
move, unable to stay still o If yes, do you have the means?
o Bradykinesia - slowness in Ø Imminent risk MOOD
movement when initiating o Immediate psychiatric referral, inpatient Ø Monoamine System
activities that require successive hospitalization o Serotonin (5-HT)
steps such as buttoning a shirt Ø Elevated risk but not imminent § Well being
o Tardive dyskinesia - involuntary o Aggressive treatment § Calm
movements of lips (smacking), § ↓ impulsivity
tongue, face, trunk and § ↓ sex drive
extremities SEROTONIN RECEPTOR SITES § ↓ aggression
Ø Increased risk of obesity, Type 2 DM, Ø 5-HT1A – antidepressant § ↑ appetite
hyperlipidemia, metabolic syndrome and Ø 5-HT1C, 5-HT2C – cerebral spinal fluid o Dopamine
hypothyroidism production § Make you worry
Ø 5-HT1D – antimigraine effect (anti=defense) § ↑ vigilance
Ø 5-HT2 – agitation, anxiety, panic (2 stressed) § ↑ motivation
Ø 5-HT3 – nausea, diarrhea (3 GI N/V/D) o Norepinephrine
§ Enhance concentration
§ Enhance ambition
§ Enhance productivity
PSYCHOSOCIAL MENTAL HEALTH
Complication from
Neurological disorder - hypotension, visual High dose parenteral vitamins, especially can lead to Wernicke
Korsakoff’s syndrome chronic alcohol abuse
impairment and coma; mental confusion, thiamine (vit. B1) Encephalopathy
(Wernicke-Korsakoff) (thiamine – vitamin
ataxia, stupor. (B1 is sugar for the brain)
B1)
PSYCHOSOCIAL MENTAL HEALTH
DSM V:
• Eating excessing
amount of food in 2
hours Binge eating is lack of
• Person feels lack of control over amount and
Secretive disease. Problems with erosion of
control over eating type of food 2+ times per
lingual surface of upper teeth due to excessive
• Recurrent compensatory week for 6 months.
exposure to gastric contents during vomiting. Cognitive behavior and pharmacological
Bulimia Nervosa behavior to prevent Accompanied by distress,
Hypokalemia caused by laxative and diuretic therapy. SSRIs – but NOT Wellbutrin
excessive weight gain self-anger, shame and
use is common. Pt is typically of average to
such as vomiting, frustration because of
slightly above average weight.
excessive exercise, purging. Pt is usually
laxative or diuretic obese.
abuse or fasting
• Occurs once per week
for at least 3 months
First line treatment is SSRI such as
Flashbacks, nightmares, intrusive thoughts, paroxetine and sertraline. Therapeutic trial of Comorbidities such as
Combat/war, sexual
avoidance of reminders of trauma, agoraphobia, Assessment tools such as 6-8 weeks to determine effectiveness. depression, anxiety,
PTSD assault, MI, stroke,
sleep disturbance and hypervigilance, feelings PTSD checklist Mirtazapine for sleep. Cognitive behavioral antisocial disorder and
ICU stay
of detachment therapy, Eye movement desensitization and substance abuse is higher
reprocessing (EMDR).
Benzos – limited duration, addiction concern
behavioral treatment and SSRI to kick in and
GAD – excessive worry then wean off Benzo Herbs: Kava-kava,
Situational, Phobias, Panic disorder occurs more in women than men
Anxiety occurs on more days than not GAD – SSRI, SNRI, buspirone valerian root and passion
OCD, Generalized with agoraphobia
for 6 months Panic disorder – SSRI, SNRI, TCA, BB, flower
MAOI
OCD – SSRI, SNRI, TCA
TOBACCO CESSATION
Ø Nicotine gum use: Chew and park – chew gum slowly until nicotine taste appears and then park next to cheeks until the taste disappears. Repeat pattern
several times and discard after 30 minutes of use
Ø Nicotine patches – do not use with other nicotine products. Nicotine overdose can cause acute MI, HTN, agitation.
Ø Bupropion (Zyban) decreases cravings to smoke. Patients can still smoke while on medication. Individually eventually loses desire to quit. Contraindications
include seizures, anorexia/bulimia, abrupt cessation of alcohol, benzos, stroke and brain tumor. Can increase risk of suicide.
Ø Varenicline (Chantix) – 12 weeks. Advise to quit within 1-4 weeks. Avoid prescribing to mentally unstable or hx suicide. Pilots and air traffic controllers are not
allowed to take medication.
PSYCHOSOCIAL MENTAL HEALTH
ABUSE DSM CRITERIA FOR SUBSTANCE ABUSE DISORDER
Ø Physical, emotional and sexual abuse, economic abuse, material Ø Require 2 or more of the following within past 12 months
exploitation Ø Substance use in larger amounts over longer period than intended
o Can happen at any age (↑ risk with pregnancy) Ø Desire to cut down or has tried unsuccessfully in the past
o Pattern of injury is inconsistent with story Ø Excessive time spent obtaining substance, using substance or
Ø Factors that increase likelihood of abuse recovering from substance
o Increased stress Ø Craving or a strong desire to use
o Alcohol and drug abuse Ø Inability to maintain major role obligations
o Personal hx of abuse, family hx of abuse Ø Continued substance use despite recurrent social or interpersonal
o Major loss problems related to substance use
o Social isolation Ø Substance use in potentially hazardous positions
o Pregnancy Ø Important social, occupational or recreational activities are given up
o Elderly (especially those who are frail with dementia) or reduced due to substance use
Ø Physical Exam Ø Tolerance
o Another health care provider should be in the room during exam o Needing more to get same effect
o Interview with abuser and then without o Diminished effect with same amount
o Collect visual evidence, photos, use ruler. Document in direct Ø Withdrawal
quotes. o Set of characteristic withdrawal symptoms
o Look for spiral fx, multiple healing fx, burns, welts, etc. o Same or other substances taken to avoid withdrawal
o Look for signs of neglect
o Develop a safety plan with partner abuse
o STD testing RANDOM SUBSTANCE ABUSE FACTS
Ø State things objectively, do not be judgmental Ø Often have underlying mood disorder
Ø Abuser is typically dominant in conversation Ø Young adults (18-25) are most likely to misuse RX meds
Ø BATHE Ø Chronic used of marijuana can lead to COPD
o Background – how are things at home? Work? Anything changed? Ø Alternative to methadone is buprenorphine plus naloxone
o Affect, anxiety – how do you feel about home life? Work? School? Ø Hyperthermia and racing heart is potentially life threatening with
Life in general? MDMA (ecstasy or Molly)
o Trouble – What worries you the most?
o Handling – how are you handling the problems?
o Empathy – that sounds difficult
Ø SOAP
o Support – Normalize but do not minimalize. What support do you
have?
o Objectivity – Watch your reactions to the story.
o Acceptance – personal acceptance
§ Acknowledge patient priorities
o Present focus
§ Focus on present, negotiate contract
RENAL
KIDNEYS KIDNEY FUNCTION CHRONIC KIDNEY DISEASE
Ø Body’s regulator of fluids Ø Serum Creatinine – when renal function ↓ creatinine ↑ Ø Common electrolyte disorders include
Ø Water is reabsorbed by antidiuretic hormone and Creatinine affected by age (less sensitive in elderly), hypernatremia, hypercalcemia and
aldosterone gender (higher in males), ethnicity (high with African hyperkalemia
Ø Excrete water-soluble waste (creatinine, urea, uric acid) background), muscle mass Ø Increase in creatinine from 1-2
Ø Produce erythropoietin (stimulates bone marrow to Male 0.7 to 1.3 indicates a 50% loss in renal function
produce more RBC), renin, bradykinin, prostaglandins and Female 0.6 to 1.1 Ø Creatinine clearance usually
calcitriol/vitamin D3 Ø Estimated Glomerular Filtration Rate (eGFR) approximates eGFR
Ø Average UO is 1500 mL eGFR “estimated value” – more damaged the kidneys, the Ø Creatinine is best described as a
Ø Oliguria < 400 mL day lower the eGFR. Best if patient does not eat meat 12 product related to skeletal muscle
Ø Right kidney sits lower than left due to liver displacement hours before test and is less reliable with drastic changes metabolism
in muscle mass, pregnancy and acute renal failure Ø Common causes include DM,
normal eGFR > 90 recurrent pyelonephritis, polycystic
URINALYSIS Stage 2 eGFR 60-89 kidney disease
Ø Epithelial Cells – large amounts indicate contamination; a Stage 3a eGFR 45-59 Ø Persistent proteinuria is commonly
few are normal Stage 3b eGFR 30-44 found in early development of CKD
Ø Leukocytes – normal WBCs in urine <10 Stage 4 eGFR 15-30 Ø ACEI can limit the progression of some
o Leukocyte esterase Stage 5 eGFR < 15 renal disease by reducing efferent
o Pyuria (presence of leukocytes) in males is always Ø Blood Urea Nitrogen – elevation may be caused by acute arteriolar resistance
abnormal renal failure, high-protein diet, hemolysis, CHF or drugs Ø Objective findings in
Ø Urine for Culture and Sensitivity (waste product of protein from foods eaten, dehydration glomerulonephritis include edema,
o >100,000 will also elevate BUN) RBC cast and proteinuria
Ø Red Blood Cells Ø BUN-to-Creatinine Ratio – evaluate dehydration, Ø Anemia: Normocytic, normochromic
o <5 is normal hypovolemia, acute renal failure anemia with low retic count
Ø Protein Ø Erythropoiesis is recommended with
o Indicates kidney damage CKD and Hgb < 10
o Urine dipstick detects albumin not microalbumin Ø Dialysis and transplant discussion at
KIDNEYS
(Bence-Jones proteins) Stage 4 CKD
Ø Prerenal azotemia – most common cause of acute renal
Ø Nitrites Ø Some meds that affect kidneys –
failure, kidneys are hypoperfused – which leads to acute
o Indicative of infection Allopurinol, antibiotics, digoxin,
tubular necrosis. Caused by ↓ circulating volume such as
Ø Cast lithium, gabapentin, H2 blockers, anti-
dehydration and acute blood loss; ↓ CO such as heart
o Hyaline cast are normal arrythmias
failure; excessive sequestering of fluids as in burns
o WBC cast may be seen with infection
Ø Postrenal azotemia – obstruction to urine flow and is
o RBC cast and proteinuria are diagnostic of
uncommon cause of renal failure. Such as
glomerulonephritis
glomerulonephritis
RENAL
CVA tenderness
Uncomplicated may treat as outpatient
E. Coli, Klebsiella spp. High fever, chills, dysuria, frequency, and UA – large leukocytes,
Cipro BID x 7 days or Levaquin daily
Pyelonephritis Proteus mirabilis unilateral flank pain (described as deep ache) N/V hematuria, WBC cast and
Rocephin 1 gram + Augmentin BID x 14
May have had recent UTI proteinuria
days
Urine C&S
Decreased blood flow
Abrupt onset of oliguria, edema and weight gain
to kidneys; damage to ↑ creatinine
Acute renal failure (fluid retention). Complains of lethargy, nausea Hydrate
kidneys; urine blockage ↓ GFR
and loss of appetite. Rapid ↓ in renal function
in kidney
Preferred therapy for nonmuscular-
Painless hematuria (microscopic or gross). May UA – microscopic hematuria is Risk factors: Elderly > 50;
invasive bladder cancer without evidence
appear at the end of voiding. Dysuria, frequency, the primary finding in 20% of male (73 years), smoker,
Long term use with of metastasis is transurethral resection
Bladder cancer nocturia (not related to UTI). Advanced disease individuals with bladder CA occupational exposure to
pioglitazone with intravesical chemotherapy. Despite
may complain of lower abdominal or pelvic pain, Urine C&S textile dyes and heavy
successful initial therapy, local recurrence
perineal pain, low-back pain or bone pain. Urine for cytology metals
is common
Cancer, infection, renal
calculi, coagulopathy,
UA
glomerular disease,
Gross hematuria if urine is pink, red, brown or If infection: Urine C&S
Hematuria hydronephrosis,
blood clots are present. If malignancy: Urine for
polycystic kidneys,
cytology
trauma, medications,
BPH, exercise induced
UA moderate to large
leukocytes, +/- nitrites, few Uncomplicated: Bactrim DS BID x 3 days; For men do prostate exam
RBC (inflammation) (sulfa allergic/resistance) Nitrofurantoin Only treat pregnant
C&S > 100,000 (Macrobid) 100mg BID x 5 days women with
Frequency, burning, urgency, dysuria, hematuria,
Ciprofloxacin (Cipro) 250mg PO BID – no asymptomatic bacteriuria
E. Coli, Klebsiella spp. foul-smelling urine, nocturia, lower abd. /back
UTI never normal in male – fluoroquinolones in pregnancy or <18yo UTI in pregnant women
Urinary Tract Staph. Saprophyticus, pain – NO FEVER
R/O other causes. Pyridium – leaves it orange (avoid in liver and children <3 are more
Infection (Cystitis) Proteus mirabilis Risk factors: female, pregnancy, hx of UTI, DM,
3 or more UTI in 1 year in disease) likely to progress to
failure to void after sex, spermicide use, low fluid
females – R/O other causes Complicated: Keflex, Cipro 500mg BID or pyelonephritis
intake, poor hygiene, catheterization
Levaquin 750 daily for 7-10 days
***nitrates are normal in ***Nitrofurantoin contraindicated with Renal and bladder sono
urine, nitrites can indicate renal insufficiency for UTI infants
infection
Severe colicky pain that comes in waves. Patient
Risk factors: family hx of
cannot sit still. Pain builds in intensity, lessens Toradol injection
Majority made of stones, gout, bariatric
and disappears. Associated with N/V. May have Increase fluids, strain urine
calcium oxalate; surgery, high doses
Nephrolithiasis gross or microscopic hematuria Avoid high-oxalate foods: rhubarb,
Struvite stones are vitamin C
(Urolithiasis) Stones in upper urethra or renal pelvis may cause spinach, beets, chocolate, tea and meats
found in those with hx Meds that cause kidneys
flank pain and tenderness whereas stones in lower Consider alpha blocker
of kidney infection stones: HCTZ,
urethra may cause pain radiating to testicle or Refer urology
topiramate, indinavir
labia. Both can cause abdominal pain
Acute is often self-limiting. Manage Risk factors include
UA ↑ Protein, RBCs, renal cast underlying cause and protect kidneys – infection: bacterial
Inflammation of antihypertensives, antimicrobials, endocarditis, immune
Pink or cola colored urine due to hematuria, ↑ Creatinine and BUN
glomeruli in kidney. systemic corticosteroids and immune disease: Goodpasture’s
Glomerulonephritis foamy due to proteinuria, HTN, edema of face, CT scan or kidney sono
Occurs 1-2 weeks s/p suppressants. Plasmapheresis, dialysis syndrome, SLE, or
hands, feet and abdomen, possible anemia Confirmatory diagnosis is with
bacterial infection If left untreated, can lead to kidney failure, vasculitis: polyarteritis or
Kidney biopsy HTN, electrolyte disorders and nephrotic Wegener’s
syndrome granulomatosis
WOMEN’S HEALTH
RANDOM GU URINARY INCONTINENCE
Normal healthy women of reproductive
age Types Definition Management Age
Ø Discharge – white, clear, flocculent (1/2 to 1 tsp Stress incontinence Associated with lifting, Pelvic floor exercises, Peak 45-49 yrs.
daily) laughing, sneezing, bending decongestant?
Ø Normal pH – 3.8-4.2 Overflow incontinence Frequent dribbling; due to Identify & treat underlying Older men
blockage of flow cause (BPH, MS, spinal cord
injury)
If test positive for STI then also recommend Urge incontinence Reports of strong sensation of Antimuscarinic Older women
o Syphilis, HIV and Hep B testing needing to void. “overactive (oxybutynin/Ditropan) or
bladder” – detrusor instability TCA (imipramine), Kegels
Friable cervix – brisk bleeding with cleaning with Functional incontinence Often occurs in presence of Bedside commode, raised
cotton swab mobility problems toilet seats with handles,
o Increased chance to acquire STI physical therapy for
strengthening and gait
Mixed incontinence Stress and urge incontinence Kegels
Normal findings on pelvic exam in older woman
o Flattening of vaginal rugae
Treatable Causes of urinary incontinence:
o Scant white vaginal discharge
D – Delirium
o Should not be able to palpate ovary
I – Infection (UTI)
A – Atrophic urethritis and vaginitis
P – Pharmaceuticals (diuretics, others)
E – Excessive urine output (heart failure, hyperglycemia due to undetected or poorly-controlled DM)
R – Restricted mobility
S – Stool impaction
Risk factors: obesity, pregnancy, vaginal delivery, menopause, age and diabetes.
Some foods have diuretic effects: tea, caffeine, alcohol, carbonated drinks, citrus fruits, spicy foods
URINARY INCONTINENCE
Ø During gynecological exam, instruct patient to cough (↑ intra-abdominal pressure so herniation is visible)
Ø Herniation of bladder (cystocele) – bulging anterior vaginal wall – refer for pessary placement, surgery
Ø Herniation of rectum (rectocele) – bulging posterior vaginal wall – feeling of rectal fullness, possible fecal
incontinence – Kegels, avoid straining during bowel movement, treat constipation – refer for pessary
placement, surgery
Ø Uterine prolapse – cervix descends midline into vagina; feeling that something is falling in vagina, low back pain
– avoid heavy lifting; refer for pessary or surgery
Ø Enterocele – small bowel slips into area between uterus and posterior wall of vagina. Pulling sensation inside
pelvis, pelvic pressure or pain, low-back pain, dyspareunia
BREAST CANCER WOMEN’S HEALTH CERVICAL CANCER
Ø BRCA (breast cancer susceptibility gene) Ø Pap smears start at age 21 every 3 years until 29
Ø Age 30 – pap with HPV every 5 years otherwise
Ø High risk
CERVIX every 3 years
o Family history of breast cancer (before 50)
Ø Cervical ectropion – looks like bright-red bumpy Ø Stop screening age 65 if negative hx for 15-20 yrs.
o Breast cancer triple-negative (before 60)
tissue with irregular surface on cervical surface Ø Hysterectomy with removal of cervix not due to
o Ovarian or other gynecological cancer
around os – benign and more friable. It is cancer – can stop screening
o ↓ parity, early menarche, late menopause
common with women taking birth control. It can Ø Specimen is satisfactory if both squamous epithelial
Ø Men with BRCA genes are higher risk of breast and
change in size, shape or disappear over time. cells and endocervical cells are present
prostate cancer
Sample the transformation zone Ø Atypical Squamous Cells of Undetermined
Ø Refer high risk to breast specialist
(squamocolumnar junction) when performing Significance (ASC-US)
Ø Screened using MRI and mammogram – screen 10
pap. Border of brighter red ectropion and o <20 yrs. repeat 1 year
years earlier than when family member diagnosed
smother surface of cervix – area where abnormal o 21-24 – repeat pap in 1 year
Ø More common among Ashkenazi Jews
cells are more likely to grow o 25-29 – reflex HPV and pap in 1 year
o 30+ if HPV + colposcopy, if HPV – repeat co-
UTERINE FIBROIDS
testing in 3 years
Ø Uterine fibroids (uterine leiomyoma or myoma) can
Ø Atypical Glandular Cells – (endometrial cells)
enlarge the uterus. Symptoms include heavy bleeding
premalignant or malignancy – endometrial biopsy
(menorrhagia), pelvic pain or cramping and bleeding
Ø Low-Grade Squamous Intraepithelial Lesions (LSIL)
between periods.
o 21-24 – repeat pap in 1 year
Ø Usually benign but can be malignant and cause
o 25-29 – colposcopy with cervical biopsy
uterine cancer (leiomyosarcoma)
o 30+ if HPV + colposcopy with cervical
biopsy, if HPV – repeat in 12 months or
MENSTRUAL CYCLE colposcopy
Ø Follicular Phase (Days 1 to 14) – estrogen is the Ø High-Grade Squamous Intraepithelial Lesions (HSIL)
predominant hormone – stimulates development and o 21-24 – colposcopy with cervical biopsy
growth of endometrial lining. FSH from anterior o 25+ refer for immediate excisional
pituitary stimulates the follicles into producing treatment (LEEP) or cervical conization
estrogen Ø HPV 16 and 18 cause 70% cervical cancer
Ø Midcycle (Day 14): Ovulatory Phase – LH secreted by Ø Vaccinate with Gardasil
anterior pituitary gland which induces ovulation
Ø Luteal Phase (Days 14 to 28) – progesterone
predominant hormone RANDOM PEARLES
Ø Sex 1-2 days prior to ovulation offers greatest chance Ø During puberty it is common for both girls and boys to
of pregnancy have asymmetrical breasts, gynecomastia
Ø Palpable ovary after menopause – intravaginal
ultrasound and rule out ovarian cancer
RANDOM TESTING Ø Primary Amenorrhea - Lack of menses by age 15 w/
Ø Tzanck smear – herpetic infections – lg. nuclei secondary sexual characteristics, Refer to OB –
Ø Gram stain – Neisseria gonorrhea, rarely used
secondary to pituitary, hypothalamus etc.
Ø Whiff test – for BV
Ø KOH – fungal infections
WOMEN’S HEALTH OTHER METHODS
ORAL CONTRACEPTIVES Ø IUD – risk for infection, perforation, heavy
Ø Combined oral contraceptives
ORAL CONTRACEPTIVE CONTRAINDICATIONS bleeding
o Monophasic pills (Loestrin FE) – 21 active pills; § Absolute contraindications o ParaGard – copper-bearing; effective
placebo (iron) last 7d § “My CUPLETS” 10yrs
o Biphasic (Ortho-Novum) – two progesterone o Mirena – levonorgestrel hormone;
o Migraines with focal neurological aura
doses effective 5 yrs. little more effective
or >35 migraines without aura
o Triphasic (Ortho tri-cyclin) - 21 active pills; than Paragard (Skyla) - smaller
o CAD/CVA
placebo last 7d. Hormones weekly. 3 varies. Ø Depo-Provera (6% failure rate) – injections q3
o Undiagnosed genital bleeding month, start within 5 days of cycle. Recommend
Good for acne
o Pregnant calcium with vitamin D and weight-bearing
o Extended Cycle (Seasonale) – 84 days active pill
w/ 7 free days. 4 periods per yr. – breakthrough o Liver disease or tumor exercise. Avoid >2 years. Risk for
bleeding o Estrogen-dependent tumor osteopenia/porosis. Avoid if anorexic/bulimic.
o Ethinyl Estradiol/Drospirenone (Yaz) o Thrombus/emboli – factor V Leiden May delay return of fertility – do not use if wish
drospirenone as progesterin; great for acne, o Smoker 35 or older to become pregnant in 12 months. Does not
PCOS, hirsutism, PMDD. High risk for § Relative contraindications interact with Dilantin
DT/hyperkalemia. Must check K+ levels if on o Migraines 35+ Ø Diaphragm w/ gel (13% failure rate) – after
ACEI/ARB/K+ sparing diuretic - ↑ risk blood o Smoker < 35 insertion, the cervix should be smoothly
clots, CVA, CAD o Fracture/cast on lower extremity covered. Leave in for 6-8h. Add spermicide w/
o Low dose pills contain 20 to 25 mcg of ethinyl o Hypertension every act of intercourse. Cervical cap can be
estradiol work for up to 72h - ↑risk UTI and TSS
Ø Progestin-Only Ø Condoms (18% failure rate)
o Safe for breastfeeding, “minipill” ORAL CONTRACEPTIVE PROBLEMS Ø NuvaRing (9% failure rate) leave inside for
o Take pill at same time each day Ø Unscheduled bleeding (spotting) 3weeks
o If taken late > 3 hours or miss dose, use Ø Menstrual cramps Ø Patch (9% failure rate)- risk of VTE
condoms o Mefenamic acid (Ponstel), Aleve, Advil, Ø Implants (<1% failure rate) – may take 1yr to
o Micronor – 28 days of progestin. Start taking on Anaprox ovulate after removal, weight gain. Norplant
day 1 of menstrual cycle Ø Menorrhagia – heavy bleeding good for 5yr, Nexplanon 3yr
Ø New prescriptions Ø Missing pills
o Can be started after ruling out pregnancy o Missed 1 day – take 2 now and continue
o “Quick Start” – start on day prescribed o Missed 2 days – take 2 pills for 2 days
o “Sunday Start” – first pill on first Sunday after EMERGENCY CONTRACEPTION
and finish pack (use condoms for
period – will avoid periods on weekends current cycle) § r/o pregnancy
o “Day One Start” – first pill on first day of Ø Drug interactions – anticonvulsants, antifungals, § effective up to 72h after unprotected sex
menstrual cycle (provides best protection) St. John’s wort, PCN, Tetracyclines, Rifampin § most effect within first 24h
o Follow-up in 2-3 months to check BP, side Ø Thromboembolic Warning signs: ACHES § inhibits ovulation, slows sperm and ovum
effects transport
o Abdominal pain
Ø Advantages (After 5 years of use) § Plan B – progesterone only (89% effective): take
o Chest pain
o ↓ ovarian and endometrial cancer 1st dose now, 2nd dose 12h later. If vomits tablet
o Headaches within 1 hour – repeat dose
o ↓ Dysmenorrhea and cramps ↓ prostaglandins
o Eye problems (vision changes) § Ulipristal – inhibits embryo transplantation-
o ↓ endometriosis
o Severe leg pain approved for up to 5 days after intercourse
o ↓ acne and hirsutism (↓ androgen)
o ↓ ovarian cyst (suppress ovulation) § Return if no menses w/in 3 weeks
o ↓ heavy/irregular periods thus decreasing IDA
WOMEN’S HEALTH
Middle-age or older female with painless mass Screening – ACS age 45 then Screening: BRCA
feels hard and irregular. Mass attached to skin yearly; USPSTF age 50 then standardized
and tissue (immobile) RUQ of breast most every 2 years questionnaire such as
Breast mass/CA Refer to surgeon
common location (tail of spence). Skin changes: < 30 start with ultrasound FHS-7 (if BRCA gene
dimpling, retraction, peau d’orange “orange peel”, Diagnostic Mammogram positive – consider
blood discharge, nipple displacement Breast biopsy referral for counseling)
Older female c/o chronic scaly red-colored rash,
Paget’s disease of like eczema, on nipple that does not heal; itching,
breast (Ductal skin lesion slowly gets larger and includes
carcinoma in Situ) crusting, ulceration and/or bleeding. Spreads to
areola
Acute onset red, swollen, warm area in breast of
Aggressive form of CA
Inflammatory younger women. Mimics mastitis. No distinct
More common in African
breast cancer lump. Acute onset, skin may be pitted or appear
American
bruised.
Risk factors: family hx,
Vague symptoms: abdominal bloating,
BRCA, endometriosis,
5th most common CA in discomfort, low-back pain, pelvic pain, urinary BRCA 1/BRCA 2 screening
Ovarian cancer >55, early menstruation,
women frequency, constipation. usually metastasized by starts at age 30
nulliparous, obesity, late
diagnosis
menopause, infertility,
Sexually active, amenorrhoeic or light to scant
bleeding, one sided lower abdominal/pelvic pain
Quantitative HCG – should Leading cause death 1st
Ectopic pregnancy 6-8 weeks after LMP w/ cramping worsening when supine or with
double 24-72 hours trimester of pregnancy
jarring. May refer to right shoulder, hx PID, tubal
ligation, or previous ectopic
Bilateral breast tenderness and lumps up to
Avoid caffeine
2weeks prior to menses, resolving w/ menses. No
Fibrocystic disease Vitamin E and evening primrose capsules
masses, skin changes, nipple discharge, or nodes
daily. Wear bras with good support
on physical exam
Presents teenage years; hirsutism, acne, Transvag. ultrasound Low-dose oral contraceptives,
Hormonal ↑ Risk for DM2,
oligomenorrhea, amenorrhea, dark hair on face, ↑ serum testosterone, DHEA, spironolactone to control hirsutism,
abnormality, infertility, hyperlipidemia, metabolic
Polycystic Ovarian cheek, beard areas, acanthosis nigricans, androstenedione, FSH is Provera 5-10mg daily for 10-14 days
excessive androgen syndrome, endometrial
Syndrome (PCOS) mood/mental health problems normal or low, FBS and OGTT (repeat every 1-2 months), metformin to
production, insulin hyperplasia, obesity, OSA,
Rotterdam Criteria (2 of 3): Oligomenorrhea, are abnormal; induce menses, weight loss
resistance CAD, breast CA
hyperandrogenism and cystic ovaries
Weight-bearing exercises (yoga, calcium w/ Vit D
(1200/800mg), Bisphosphonates: 1st line ↑
BMD and inhibits bone reabsorption (potent
“Skinny white woman who smokes and drinks” – esophageal irritant, take with full glass of water Long term
Affects women and men while sitting or standing and do not lay down for bisphosphate tx
Common fx sites include femur, forearm, 30 minutes) Fosamax (alendronate), Actonel has been
vertebrae; ↑ risk with chronic steroid use, hx of DXA scan: T-score < -2.5
(risedronate), Selective Estrogen Receptor associated with
(Osteopenia: -1.0 to -2.4)
Loss of bone density anorexia or bulimia, long term PPI use, gastric Modulator – block estrogen receptors. Good for atypical fx. – give
Osteoporosis Repeat DXA in 1-2 yrs. if on
from estrogen def. bypass, celiac disease, hyperthyroidism, postmenopausal women with osteoporosis who for 5 years and
meds otherwise in 2-5 yrs.
ankylosing spondylitis, Caucasian and Asian also need breast cancer prophylaxis. ↑ risk DVT, then take break.
women. Lifestyle risk factors - ↓ Calcium, vitamin endometrial cancer, strokes and PE. Evista Use of calcitonin
D, inadequate physical activity, alcohol (raloxifene) after menopause. Parathyroid has ↑ risk of
consumption (3+ per day), ↑ caffeine, smoking hormone (PTH) Analog – Forteo; Miacalcin and malignancy
Calcitriol – weak compared to bisphosphonate.
Low calcium diet and monitor for hypercalcemia,
hypercalciuria and renal insufficiency.
WOMEN’S HEALTH
Late third trimester pregnancy with sudden onset ↑ Risk with HTN,
Placental Abruption
vaginal bleeding accompanied by contracted CBC, PT/PTT, Type Deliver fetus; severe case can cause preeclampsia/eclampsia,
(Abruptio
uterus, painful. Hard abdomen, rigid uterus. Up and Cross, Rh, sono hemorrhage cocaine use or hx of abruptio
Placentae)
to 20% do not have vaginal bleeding placentae
Bedrest. Mag sulfate for cramping. If mild,
Multipara late 2nd to 3rd trimester with new onset uterus will reimplant. No vaginal or rectal ↑ risk hx., C-section, multipara,
Placenta Previa painless bleeding worsened by intercourse. Soft, stimulation. If cervical dilation or older age, smoking, fibroids,
nontender uterus. hemorrhaging, fetus is delivered via C- cocaine
section
Primigravida in late 3rd trimester (>34 weeks);
Triad: HTN,
sudden onset recurrent headaches, visual
proteinuria and edema
Unknown – risk factors: abnormalities (blurred vision, scotomas) and
> 20 weeks
primigravida, pitting edema. Edema easity seen on face/eyes HTN before 20 weeks is HTN –
BP > 140/90 Delivery – can occur up to 4 weeks after
Preeclampsia multipara, > 35, and fingers. Sudden rapid weight gain in 1-2 days. may be able to get off meds
Proteinuria 0.3 gram delivery
obesity, prior hx., HTN New onset RUQ pain, BP > 140/90 with urine during 1st and 2nd trimester
in 24 hours
or kidney disease protein 1+, oliguria. N/V are worrisome for
Edema face, eyes,
encephalopathy. Can start at 20 weeks. If
hands
seizures, Eclampsia.
↑AST, ALT, lactate
HELLP (Hemolysis,
Serious but rare dehyrogenase
Elevated Liver Signs and symptoms of preeclampsia that present
complication of Total Bili > 1.2 Multipara > 25
Enzymes, and Low suddenly
preeclampsia/eclampsia Platelets <100,000
Platelets)
↓ H/H
RhoGAM (anti-D immune globulin) made
Maternal immune system produces antibodies from pooled IgG antibodies. If not given, this
against Rh-positive blood if not given RhoGAM. Coombs: detects Rh will result in fetal hemolysis in future
Rh-negative mother
Rh-incompatibility Give for all pregnancies of Rh-negative mothers – antibodies (indirect) pregnancies. ↓ risk by destroying fetal Rh+
with Rh-positive fetus
even if they terminate in miscarriage, abortion, and infant (direct) RBC that have crossed placenta
ectopic etc. RhoGAM 300mcg IM – first dose 28 weeks
2nd dose within 72 hours of delivery
One-Step Method – 75 g OGTT –
fasting (8 hrs.) >92
1 hour >180
2 hours >153
Screen at first visit if
Two Step Method – 50 g OGTT (not fast)
high risk otherwise
Associated with higher rates of neural tube Check plasma glucose at 1 hour (if > 140 –
screen at 24-28 weeks
defects, congenital heart disease, birth trauma order 100 g OGTT –
(shoulder dystocia), preeclampsia, hydramnios, Fasting (8 hrs.) > 95
Diabetes in 1st
Gestational macrosomia, fetal organomegaly and neonatal 1 hour > 180
trimester = Type 2 Higher risk for Type 2 diabetes
Diabetes hypoglycemia. Risk factors – hx, obesity, Asian, 2 hours > 155
diabetes
Native American, Pacific islander, black, 3 hours > 140
Hispanic, infant > 9lbs, older than 35 Glycemic targets –
Test 6-12 weeks
Preprandial 95 or less
postpartum and every
1 hour < 140
3 years afterwards
2 hours < 120
A1C goal: 6-6.5%
Lifestyle measures → insulin, glyburide,
metformin
SEXUALLY TRANSMITTED DISEASES
N. gonorrhoeae, C.
Irritating voiding symptoms, fever, Ceftriaxone 250mg PO plus
Pelvic trachomatis,
abdominal pain, cervical motion doxycycline 100 mg BID x 14 days
inflammatory bacteroides, ↑ risk for ectopic pregnancy and/or infertility
tenderness, adnexal tenderness, vaginal with or without metronidazole
disease Enterobacteriaceae,
discharge. 500mg PO BID x 14 days
streptococci
Metronidazole (Flagyl) 2gram PO
Exam: “strawberry”
Dysuria, bubbly itching, vulvovaginal or tinidazole 2gram PO or 500mg
Trichomonas cervix w/ some bleeding
irritation, yellow-green vaginal PO BID x 7 days. Abstain from
Trichomoniasis Vaginalis Protozoan Wet smear: motile
discharge, occasionally frothy. alcohol use until treatment
parasite w/ flagella protozoa flagella and
complete. Treat sexual partner;
large # WBC
avoid sex until treatment complete
Screening:
Annual screening < 25 for sexually active Chlamydia and gonorrhea
HIV: annual testing for syphilis, chlamydia and gonorrhea
Men having sex with men: annual screening chlamydia and gonorrhea, pharyngeal gonorrhea, HIV, syphilis and HBsAg
Pregnant women: HIV, chlamydia, gonorrhea, syphilis HBsAg at initial prenatal visit
MEN’S HEALTH
PROSTATE GLAND RANDOM PEARLES
Normal prostate
Firm, smooth, Firm as pressing Ø Sperm produced in seminiferous tubules of testes
(See A below) nontender in on tip of your Ø Sperm require about 3 months to mature (stored in epididymis until mature)
nose Ø Production of testosterone is stimulated by release of luteinizing hormone
Acute prostatitis Tender, boggy, Firm as pressing Ø Spermatogenesis is stimulated by testosterone and follicle-stimulating hormone
indurated in over your
Ø Transillumination for evaluating testicular swelling, mass, bleeding or cryptorchidism
cheekbone
o Hydrocele will transilluminate
BPH firm, smooth Firm as pressing
(See B-F below) symmetrically in on tip of your o Tumor and varicocele (bag of worms) will not transilluminate
enlarged nose Ø Postrenal azotemia – can be due to prolonged urinary obstruction leading to hydronephrosis and
Prostate cancer Asymmetric, Usually malignant compromised renal failure
Nodular, hard, lesions not Ø Only scrotal edema and no pain – assess for generalized weakness and refer to urology
nontender palpable until
disease is
advanced
Produces PSA
MEN’S HEALTH
Abrupt onset extremely painful and swollen red Loss of cremasteric reflex (testicle
Most common between
scrotum. Frequent has N/V, affected testicle elevated toward body with urologic emergency
Spermatic cord 10-20; more common
Testicular Torsion located higher and closer to body than stroking inner thigh) 6h window for survival >85%
becomes twisted with bell clapper
unaffected testicle. Left side more often affected UA Orchiopexy to prevent recurrence
deformity
Ultrasound (done in ED)
Acute or chronic swollen red scrotum that’s
CBC, UA, C&S, + Prehn’s sign
painful w/ unilateral testicular tenderness and <35 -Doxycycline x 10d Infertility is possible post
Inflammation (relief of pain with scrotal
Epididymitis discharge. Scrotum is swollen and erythematous >35 – Ofloxacin or levofloxacin x 10d infection due to scarring
(can be infectious) elevation) + Cremasteric reflex
w/ induration of the posterior epididymis, s/s NSAIDs, scrotal support/elevation of vas deferens
Check for STI
UTI; most common when people sit too long
Vascular insufficiency Phosphodiesterase 5 inhibitor – take
(diabetes, HTN), Viagra on empty stomach
Concomitant nitrates,
Erectile neuropathy, Inability to have an erection firm enough to Viagra or Levitra – take prior to sex
caution alpha-blockers,
dysfunction medications (SSRI, perform sexual intercourse Cialis – take within 36 hours of sex
recent MI, post CVA
BB), smoking, alcohol, May cause headache, flushing, dizziness,
hypogonadism hypotension, nasal congestion, priapism
Scrotal ultrasound
Varicose veins in scrotal sac (“Bag of worms”) –
Treatment if causing pain, atrophy
Abnormally dilated only present in standing position. New onset can May have decreased
Varicocele or infertility includes -surgery or
spermatic vein signal testicular tumor or mass impeding venous sperm count
percutaneous embolization
drainage; may have recurrent scrotal pain
Scrotal support can help
Non-communicating
Collection of serous fluid that causes painless
Underlying cause may Scrotal ultrasound disappears within 1st year
Hydrocele scrotal swelling, easily recognized by
be hernia Refer to urologist of life – scrotum will look
transillumination
like deflated balloon.
ELDERLY
DELIRIUM VS DEMENTIA DELIRIUM ETIOLOGY
DELIRIUM DEMENTIA Ø Drugs – when any medication is added, or dose adjusted. (Anticholinergics, TCA,
Sudden state of rapid Slowly developing antihistamines, antipsychotics, opioids, opiates, benzodiazepines, alcohol, etc.)
changes in brain impairment of
function reflected in intellectual or cognitive Ø Emotional – mood disturbances, loss
confusion, change in function that is Electrolyte disorder (hyponatremia)
cognition, activity and progressive and Ø Low PO2 – CAP, COPD, MI, Pulmonary edema
LOC interferes with normal Lack of drugs
functioning
Etiology Acute underlying cause Variety of causes Ø Infection – UTI, CAP
such as acute illness Ø Retention of urine or feces
Onset Abrupt, over hours to Insidious that cannot be Reduced sensory input (blindness, deafness, darkness, change in surroundings)
days. related to a precise date,
Ø Ictal or post ictal state
gradual change in
mental status. Ø Undernutrition – protein/calorie malnutrition, vitamin B12 or folate deficiency,
Memory Impaired but variable Memory loss, especially dehydration
recall for recent events Ø Metabolic – diabetes, thyroid,
Duration Hours to days Months to years
MI
Reversible Usually reversible Chronically progressive
and irreversible Ø Subdural hematoma
Sleep disturbance Disturbed sleep-wake Disturbed sleep-wake
cycle with hour-to-hour cycle but lacks hour-to-
INTERVENTION
variability often worse as hour variability, often Ø Assess those at greatest risk
day progresses day-night reversal Ø Treat underlying condition
Psychomotor Usually a change, None until late in
hyperkinetic, hypoactive disease
or mixed. None in DEMENTIA ETIOLOGY
almost 15% Ø Alzheimer-type 50-80% (loss of executive functioning)
Perceptual Disturbances Yes, including None until later in the
Ø Vascular dementia - 20% (memory loss after stroke)
hallucinations disease
Ø Parkinson disease – 5%
Speech Incoherent, confused In early stages
with inappropriate Ø Misc. – HIV, dialysis encephalopathy, neurosyphilis, normal pressure
words hydrocephalus, Pick’s disease, Lewy body disease, frontotemporal dementia
STANDARDS FOR ALZHEIMER CARE ELDERLY PEARLS MEDS TO AVOID IN ELDERLY
Ø To slow the decline in dementia Ø Top 3 leading cause of death > 65 Ø Anticholinergic Effects
o Vitamin E 1000U BID or o Heart disease (MI, heart failure, o Tricyclic antidepressants
o Selegiline 5mg BID arrhythmia) o Overactive bladder medications
Ø Mild to moderate stage disease o Cancer (lung and colorectal) o First generation antihistamines
o Cholinesterase inhibitors o Chronic lower respiratory disease o Dry as a bone (dry mouth/eyes)
§ Donepezil (Aricept) (COPD) o Red as a beet (flushing)
§ Rivastigmine (Exelon) Ø Fasting growing age is 85+ o Mad as a hatter (confusion)
§ Galantamine (Razadyne) Ø Young old is considered 65 to 74 o Hot as a hare (hyperthermia)
o Clear minor benefits Ø Any unexplained iron-deficiency anemia who is o Can’t see (vision changes)
Ø More advanced dementia older, male or postmenopausal should be o Can’t pee (urinary retention)
o N-methyl-D-aspartate receptor referred for colonoscopy o Can’t spit (dry mouth)
antagonist memantine (Namenda) Ø If chemistry shows ↑ calcium or alkaline o Can’t shit (constipation)
Ø Treat agitation and depression phosphatase, indicative of cancerous metastasis Ø Significant risk of orthostatic hypotension
Ø Consider non-AD related reasons for behavioral of bone o Tricyclic antidepressants
issues Ø Depression is very common in dementia Ø Increase in fall and fracture
o Pain, infection Ø Cholinesterase inhibitor side effects include o Sleep medications
Ø If environmental manipulation fails nausea and diarrhea Ø Potential to promote fluid retention
o Psychotropic (risperidone) Ø Syncope o NSAIDs
Ø Dizziness Ø Increased risk for hyponatremia
Ø Vertigo o SSRI
ELDER ABUSE o Start elderly on SSRI and recheck in one
Ø Presence of bruising, skin tears, lacerations and month (esp. those taking thiazides)
fractures that are poorly explained Ø Use in caution with BPH, narrow-angle glaucoma
ACTIVITIES OF DAILY LIVING
Ø Presence of sexually transmitted disease, vaginal and preexisting heart disease.
Ø Ability to feed self
and/or rectal bleeding, bruises on breast are
Ø Ability to manage bowel and bladder elimination
indicators of possible sexual abuse
Ø Personal hygiene and grooming ASSESS FOR FALL RISK
Ø Malnutrition, poor hygiene, and pressure injuries
Ø INSTRUMENTAL ACTIVITES OF DAILY LIVING
Ø Screen for abuse and financial exploitation Ø Timed Get up and Go
o Grocery shopping
Ø Interview alone:
o Housework
o Do you feel safe where you live?
o Managing finances
o Who handles your checkbook and
o Using telephone
finances?
o Driving a car
o Who prepares your meals?
ELDERLY
BODY AND METABOLIC CHANGES BODY AND METABOLIC CHANGES
Ø Skin and Hair – atrophies, less elasticity due to less subdermal fat and collagen. Ø Eyes – presbyopia – loss of elasticity of lenses and difficulty in focusing on
Fragile and slower to heal. Xerosis (dry skin) due to ↓ sebaceous and sweat objects up close. Onset mid 40’s – reading glasses. Need more illumination,
gland activity (↑ risk dehydration, heat stroke). ↓ in vitamin D synthesis. Fewer increased sensitivity to glare, washing out of colors.
melanocytes which contributes to gray hair. o Arcus Senilis – opaque gray to white ring in margin of cornea or on
o Seborrheic keratoses – soft wart-like skin that appear pasted on; found periphery of iris, develops gradually and not associates with visual
mostly on back; color can range from tan, brown to black; benign changes. Caused by deposit of cholesterol and fat. If less than 40 –
chest fasting lipids.
LIVE IMMUNIZATIONS
IMMUNIZATIONS
Ø Spacing of Vaccines Ø Must replicate to reproduce immunity – run fever and/or rash
o 4 days before due is ok – 5 days prior is INVALID Ø Avoid before age 1
Ø Hepatitis A Ø MMR
o Universally recommended age 1 o 12-15 months and age 4-6
o 2 dose series at least 6 months apart Ø Varicella
Ø Hepatitis B o 12-18 months and age 4-6
o 3 dose series: 0, 1-2 months, 6 months o If given at age 13 or later, 2 doses are required at least 1 month apart
Ø DTaP (< 7 years) – minimum age 6 weeks o Contraindicated if allergic to neomycin or gelatin
o #1 at 2 months Ø Must wait 28 days between live vaccines
o #2 at 4 months
o #3 at 6 months
o #4 at 15-18 months
ADVERSE REACTIONS TO IMMUNIZATIONS
o #5 at 4-6 years Ø Local (redness), systemic (fever) or allergic
Ø Tdap > 7 years Ø Syncope with HPV, MCV4 and Tdap
o 11-12
o Td booster every 10 years
o Every pregnancy 3rd trimester RULES ABOUT NODES
Ø Hib Ø 10mm is enlarged
o 2, 4, 6 and 12-15 months Ø Exceptions
o For unvaccinated 15+ months administer only one dose o Epitrochlear > 5mm
Ø Pneumococcal vaccine (PCV13) o Inguinal > 15mm
o 2, 4, 6 and 12-15 months o Cervical > 20mm
o Vulnerable populations also get PCV23
Ø Polio (IPV only)
o 2, 4, 6-18 months and age 4-6
o Contraindicated for allergies to neomycin, streptomycin or polymyxin B
o No more oral polio due to live vaccine
Ø Flu vaccine
o Every year
Ø Meningococcal Conjugate vaccine (MCV4)
o All children age 11-12
o BOOSTER age 16
Ø HPV-9
o Age 9-14 – 2 dose series at 0 and 6-12 months
o Avoid in pregnancy, ok if breastfeeding
DEHYDRATION PEDIATRICS
Mild Moderate Severe
Pulse Normal Rapid Rapid and weak CONGENITAL HEART DISEASE
BP Normal Normal to low Ø Innocent Murmur Clues:
low
o Grade < 2
Respiration Normal Deep, ↑ Deep, ↑ rate
rate o Softer when sitting than when supine
Mucosa Sticky Dry Parched o Not holosystolic
Anterior fontanel Normal Sunken Very sunken o Minimal radiation
Eyes Normal Sunken Very sunken o Musical or vibratory quality
Skin turgor Normal Reduced Tenting
Ø Pathologic Murmur Clues:
Skin Normal Cool Cool, mottled
Urine output Normal Reduced None o Grade > 3
Systemic signs Thirsty Irritable Lethargy o Holosystolic
Can they hold fluids down? o Max intensity at LUSB
o Harsh or blowing
o Systolic clicks
UNDESCENDED TESTES o Diastolic murmur
Ø ↑ risk of testicular cancer o ↑ intensity in upright position
Ø Cryptorchidism – undescended o Gallop rhythm
Ø Retractile testes – moves between scrotum and o Friction rub
inguinal ring
Ø Refer if not descended by 6 months
PINWORMS
Ø Enterobiasis
Ø Scotch tape test in the morning to look for eggs
o Worms come out at night and lay eggs in anal
area
o Check several days in a row since females do
not lay eggs every day
Ø Usually happens 4-8 weeks after exposure
Ø Treat with Albendazole
Ø
PEDIATRICS
Physiologic jaundice
Physiologic jaundice
occurs after 24 hours of
occurs in absence of Usually seen in face and progress caudally to
Prevention: encourage breastfeeding every life
Jaundice liver disease; jaundice trunk and extremities
2-3 hours daily Jaundice within first 24
arise from problems
hours of life typically
with liver
involves liver problems
Breast milk production in the absence of lactation,
Some cultures think this is a curse so be
Maternal hormonal usual onset day 3-4 of life. Breast engorgement
Galactorrhea sure to ask how if this has any effect on the
influences will resolve without intervention within first 2
family.
months of life.
Erythema Parvovirus B19 – “slapped cheek” rash; lacy, maculopapular When can child go back to
Infectiosum spread through resp. Significant risk of miscarriage in pregnant mother Self-limiting daycare – fever free for 24
“Fifth disease” secretions if exposed particularly in 1st trimester hours
Fever, malaise, sore mouth, anorexia; 1-2 days Do not confuse with
Hand, foot and
Coxsackie A Virus later, lesions; can also cause conjunctivitis and Prevent dehydration – resolves in 2-3 days herpangina – sores in
mouth disease
pharyngitis; last 2-7 days mouth
Hot potato voice, difficulty swallowing, trismus Airway maintenance, ED, ENT consult,
Peritonsillar abscess Bacterial and contralateral uvula deviation; possible antimicrobial therapy, inpatient
stridor admission, surgical intervention
Hyperactivity, Impulsivity and inattention Document > 6 symptoms of inattention Do not confuse with
Symptoms must be present
Use rating scale (Child behavior checklist, someone who has
prior to age 12 years;
Combined: meets criteria of BOTH inattention Conners’ rating scales, Vanderbilt ADHD sensitivity to
ADHD symptoms last > 6 months;
and hyperactivity/impulsivity rating scales, others) decongestants;
Be evident in 2 different
Predominantly inattentive If co-morbidities are present – refer hyperthyroidism;
settings (school and home)
Predominately hyperactivity/impulsivity Commonly treated with Schedule 2 meds pinworms
Commonly viral
Chest x-ray High dose amoxicillin 90 mg/kg/day
Pneumonia If bacteria – Strep Most sensitive finding is ↑ respiratory rate
CBC
pneumo
Narrowing of pyloric
Differential diagnosis: GERD, milk
sphincter due to Projectile vomiting, first-born males, nonbilious Typically occurs at 4-6
Pyloric Stenosis ultrasound protein intolerance, intestinal obstruction
hypertrophy of pyloric vomiting. Olive like mass palpated in RUQ weeks;
Surgery
muscle
PEDIATRICS
Trendelenburg’s (stand on
Legg-Calve Perthes Avascular necrosis of Ages 3-12
Limp; pain to hip and/or knee affected side causes pelvic tilt) Refer to ortho
Disease proximal femoral head Affects males > females
Hip x-ray (AP and frog leg)