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355 Cards in this Set
- Front
- Back
What does SNOOP stand for in reference to headaches?
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Use this when you are considering diagnosis other than primary headache, these are the red flags.
S- systemic: fever, HA, preg, HIV etc. N- neurological symptoms: confusion, AMS, nuchal, cranial nerve abnormalities O- Onset: sudden, with exertion, O: onset- age P:previous history |
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At what ages are headaches more serious?
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>50 and <5
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What should you suspect with a thunder clap headache?
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Sub arachnoid
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What kind of headache is pressing, non-pulsatile pain, that lasts 30 minutes to 7 days, and is usually bilateral?
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Tension headache
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What kind of headache last 4-72 hours, is usually unilateral, pulsing quality, aggravated by activity and is accompanied by either nausea, vomiting, photophobia or phonophobia?
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Migraine headache
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When does the aura occur with migraines?
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Typically before or during
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What are some examples of an aura that occurs with migraines?
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feeling o dread, anxiety, fatigue, nervous, Gi upset, visual or olfactory alteration
NO AURA should last >1 hours- consider alt. dx |
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What type of headache occurs most commonly with males?
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Cluster
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What type of headache presents in groups at typical times of the year/day, usually unilateral, and is associated with increased lacrimation, conjunctival injection, ptosis and nasal stuffiness?
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Cluster
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Which headache is associated with the release of histamine?
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CLuster
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Which headache is associated with "hot poker" eye?
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Cluster
|
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Which headache do people complain of an "alarm clock" headache?
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Cluster.
Headache awakens them from sleep |
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Which headache is called suicide headache?
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Cluster
follow a crescendo, decrescendo pattern |
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What are some prophylactic medications for headache?
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BB, Ca blockers (verapamil), TCA's, anitepileptic drugs (neurontin) and lithium (cluster HA's)
Goal is to reduce severity and frequency and allow rescue medications to be more effective |
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Which headache medications are specific to migraines?
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Triptans (SSRI agonists, Imitrex rizitriptan)
Ergot derivatives (ergotamine- vascular suppressant) |
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What is the most important differential dx in headache?
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hemorrhage
Detect with CT (acute), 2nd MRI (days to weeks) |
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What type of headache medications are rizatriptan and ergotamine?
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abortive migraine therapy
|
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What kind of headache medication is propanolol or verapamil?
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Preventative/prophylactic
|
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What is the most serious complication of giant cell arteritis?
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Blindness
Inflammation of the lumen of the vessel The temporal artery feels like a cord and you can palpate it. It is very painful for the patient |
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What is giant cell arteritis associated with ?
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Polymyalgia rheumatica
Autoimmune imflammatory disorder, characterized by pain in neck, shoulder, hip assoc. with fever, anemia "illness" and morning pain |
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What is Reiter's syndrome?
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Reactive arthritis, can't see can't pee can bend the knee.
Autoimmune usually triggered by bacteria, find source treat it, NSAIDS and immune agents |
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How to you treat giant cell arteritis?
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6 months to 2 years of corticosteriods
|
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What are some common side effects of steroids?
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peptic ulcer
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What medication is known to cause duodenal ulcers?
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NSAIDS
|
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Which medications will help with duodenal ulcers?
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PPI's (nexium, protonix and the -azoles)
H2RA's don't prevent ulcers (-adine group, pepcid) |
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What is alendranate?
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Fosamax.
Helps prevent bone demineralization. Also use to counteract steroid side effects (bone loss) |
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What is mispristol/cytotec?
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Used to prevent ulcers - increases the thickness of the lining of the stomach.
Abortions, induce labor- synthetic prostaglangins. Use to counter act NSAID use |
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What is beta lactamase?
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Enzyme produced by bacteria that breaks down antibiotics.
Many antibiotics have a beta lactam ring, so when a bacteria possess beta lactamase it will render the medicine ineffective and win the fight! |
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What are in the most common pathogens in pneumonia? (CAP)
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1- S. pneumoniae (g+)
2- M. pneumonae & C. pneumoniae (atypical, no cell membrane) 3- H. Influenzae (g-) 4- Legionella (atypical, no cell wall) |
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What are the risk factors for DRSP?
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1- recent antibiotic use
2- day care 3- > 65 y/o 4- ETOH abuse 5- medical comorbidities and immunosuppression |
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Why use caution with telithromycin?
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LIVER
macrolide derviative acid stable antibiotic |
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A college kid presents with pneumonia, what bacteria is the likely cause?
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M. pnuemoniae & C. pneumoniae.
Tx with macrolide because produces beta lactamase |
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A male that smokes presents with pneumonia, what bacteria is likely to be the cause?
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H. influenzae
tx with macrolide, cephalosporin, flouroquinolone, augmentin or tetracycline. |
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Where would Legionella most likely be found?
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Mist or aspiration from a water source or liquid. Air conditioner, shower or fountain.
Not spread from person to person. Tx with macrolide, flouroquinolone, or doxycycline Presents as dry cough, not classic s/s. |
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Can you give doxycycline in pregnancy?
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No stains teeth, preg category D.
|
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Which 2 antibiotics are potent CYP3A4 inhibitors?
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Clarithromycin and erythromycin. Will increase potency of subtrates.
|
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If a patient has comorbidities and you are treating them for pneumonia, what antibiotic should you use?
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Fluoroquoinolone.
Levaquin |
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Which bacteria causes pneumonia in the acute care setting?
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Pseudomonas Aureginosa (g-)(ventilator patients)
S. Aureus, K. Pneumonia |
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Which bacteria most often causes "walking pneumonia"
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M. pneumoniae
Presents with normal vitals, bilateral inspiratory crackles, and infiltrates on CXR |
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If you percuss with pneumonia the sound will be ----------
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dull
|
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Tactile fremitus with pneumonia will be increased or decreased?
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Increased
|
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How do you prescribe zithromax when treating pneumonia?
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500mg daily for 3 days
do not use Z-pack |
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What are neutrophils?
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Most abundant type of red blood cell.
60% of WBC's Seen with BACTERIAL infection aka PMN, segments |
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What are lymphocytes?
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30% of WBC's
Seen with VIRAL infections. |
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What are monocytes?
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6% of WBC's
elevated with FB, splinted, debris sign of tissue damage |
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What are eosinophils?
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3% of WBC's
Seen with ALLERGENS or PARASTIES Giardiasis infection, addison's disease as well |
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What is the breakdown of WBC's?
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60 neutrophils
30 lymphocytes 6 monocytes 3 eosinophils 1 basophils "nobody likes my educational background' |
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What does a shift to the left mean?
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Elevated WBC's
Elevated Neutrophils > 70% bandemia (increased immature neutrophils >400/mm3 or greater than 4%) |
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What are BANDS?
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Immature white blood cells that are called up from the bone marrow to fight significant bacterial threat.
Called BAND because nucleus is in the shape of a band. Normally 0-4% are present in circulation. |
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How do you calculate the absolute neutrophil count?
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ANC= % neutrophils x total white blood cells
Same for all other, just multiple the % to get the actual count |
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What is the most common cause of acute bronchitis?
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Virus
|
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What URI presents with a protracted cough?
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Pertusis, whooping cough.
Cause by B. pertussis Tx: macrolide or tetracycline may also want steroid with protracted cough :) |
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What does asthma consist of?
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airflow obstructions, bronchial hyper-responsiveness, and underlying inflammation
|
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What is the key to making the diagnosis of asthma?
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Spirometry.
Use peak flow to continually monitor |
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What are controller drugs for asthma?
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Inhaled corticosteroid: Asmanex- mometasone, Flovent- fluticasone, Budesonide-Pulmacort (decreased inflammatory mediators)
Leukotriene receptor antagonist & leukotriene modifiers: montelukast-Singulair (inhibits leukotrienes, which are fatty compounds produced by the immune system that cause inflammation in asthma and bronchitis, and constrict airways) Mast cell stabilizers: cromolyn-intal, nedocromil Tilade (stabilizes cell so doesn't release histamine) |
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How much of inhaled corticosteroids are systemically absorbed?
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<20%
|
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How should the LABA be used?
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With ICS. Not advised to use alone.
Increased risk for asthma death with certain groups. AA. Can cause rebound life threatening exacerbation. |
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What are some examples of long acting beta agonists?
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salmeterol (servent)
formoterol Now made in combination: in products like Symbicort (budesonide with formoterol) and Advair (fluticasone with salmeterol) |
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What are rescue medications for ACUTE Asthma?
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SABA- albuterol (salbuterol), levalbuterol (xopenex)
Steroids during acute flare for 3-10 days |
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What is the therapeutic index for theophylline?
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10-20
need periodic monitoring too many contraindications mild to moderate bronchodilator |
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What is omalizumab (Xolair)
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Recombinant DNA dervied IgG monoclonal antibody that selectively binds to IgE on the surface of mast cells and basophils. Decreases the release of mediators of the allergic response.
Rx by specialist. $20,000 a year -mab (monoclonal antibody technology) |
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How should the LABA be used?
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With ICS. Not advised to use alone.
Increased risk for asthma death with certain groups. AA. Can cause rebound life threatening exacerbation. |
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What are some examples of long acting beta agonists?
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salmeterol (servent)
formoterol Now made in combination: in products like Symbicort (budesonide with formoterol) and Advair (fluticasone with salmeterol) |
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What are rescue medications for ACUTE Asthma?
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SABA- albuterol (salbuterol), levalbuterol (xopenex)
Steroids during acute flare for 3-10 days |
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What is the therapeutic index for theophylline?
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10-20
need periodic monitoring too many contraindications mild to moderate bronchodilator |
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What is omalizumab (Xolair)
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Recombinant DNA dervied IgG monoclonal antibody that selectively binds to IgE on the surface of mast cells and basophils. Decreases the release of mediators of the allergic response.
Rx by specialist. $20,000 a year -mab (monoclonal antibody technology) |
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Intermittent asthma: symptoms and treatment
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symptoms & inhaler use <2 days a week, NO interference with activity
FEV >80% Tx: SABA prn |
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Mild asthma: symptoms and treatment
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symptoms & inhaler use 2 days a week, minor limitation
FEV> 80% Tx: low dose inhaled corticosteroid +SABA |
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Moderate asthma: symptoms and treatment
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symptoms & inhaler use daily, some limitation
FEV>60% but less than 80% Tx: Medium dose ICS +SABA |
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Severe asthma: symptoms and treatment
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symptoms & inhaler use multiple times throughout the day, extremely limited
FEV <60% Tx: ICS, possible oral steroids, + SABA |
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What is the most common type of asthma?
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Moderate persistent
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What is considered well controlled asthma?
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2 or less times a week with symptoms
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Corticosteroids cause which type of ulcer?
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Gastric
|
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When is there spirometric evidence of airway obstruction?
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if the FEV1/FVC <70% (0.70)
This is important because subject symptoms are occasionally absent |
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What is FEV1
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Forced expiratory volume in the first second of expiration
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What is FVC
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forced vital capacity, total respiratory effort
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What is used to treat mild COPD
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SABA
FEV1 >80% |
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What is used to treat moderate COPD
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long acting bronchodialtors- Spiriva, Atrovent, Serevent, formoterol and SABA
|
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What is used to treat Severe COPD
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ICS, long acting bronchodilators and SABA
** ADVAIR and SYMBICORT** |
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What is used to treat Very severe COPD
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LONG term oxygen and other treatments. ICS, long acting bronchodilators and SABA
|
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What is Advair?
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Fluticasone and salemeterol
ICS & LABA |
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What is the goal of oxygen therapy in COPD?
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To bring sp02 higher than 90%
ps02 => 60 mmhg |
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When is it indicated to initiate long term oxygen therapy (>15 hours/day)?
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with pa02 <55 mmhg or with Sa02 <88%
or when pa02 55-59 or Sa02 = 89% in the presence of cor pulmonale, right heart failure or polycythemia (hct >56%) |
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How should o2 be used?
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Minimum of 15 hours a day
A vasodilator that decreases the workload of the heart don't wait to take it when SOB |
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What is cor pulmonale?
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Enlarged righth ventricle due to pulmonary hypertension
increased resistance = increased pulmonary blood pressure |
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When do you add steroids to a COPD exacerbation?
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When FEV1 < 50%
add for 10 days |
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What findings are most common with inhalation anthrax?
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Fever, malaise, widened midastinum, and DRY cough.
Patients with inhalational anthrax present initially with nonspecific symptoms, including a low-grade fever and a nonproductive cough. They may report substernal discomfort early in the illness. After initial improvement, inhalational anthrax progresses rapidly, causing hemorrhagic mediastinitis and rapid clinical deterioration. |
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What is hantavirus?
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characterized by a febrile prodrome that was followed by acute respiratory failure and finally death due to circulatory collapse.RNA zoonotic virusesHPS occurs primarily in the fall, when small rodents (eg, field mice) inhabit human dwellings to protect themselves from the cold weather. 25% develop cardiac and may require vent.Ribavirin has been used to treat Hantavirus infections, but its efficacy in HPS remains unproven.
|
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Where does botulism come from?
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Bee honey and canned foods
C botulinum is an anaerobic gram-positive rod that survives in soil and marine sediment by forming spores |
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What bacteria breed in reheated rice?
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Bacillus Cereus
fried rice syndrome can produce a toxin that might be fatal, but usually manifests as food poisoning |
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When should diabetes testing begin?
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In the absence of symptoms start @ age 45.
Otherwise in BMI>25 and other conditions may convince you to start earlier ;) |
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In reference to laboratory testing, what results are postive for DM?
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FSBS 126 or higher
a1c => 6.5% OGTT=> 200mg/dl (75 mg load) random of =>200 |
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What the heck is prediabetes?
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FSBS =100-125
OGTT 140-199 A1c = 5.7- 6.4% |
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What does post prandial mean?
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After a meal
|
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What is the goal for A1C?
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<7 for a diabetic (ADA)
< 6 for normal population use tighter control for younger, can be a little more lenient with shorter life expectancy |
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What is a sulfonylurea?
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Insulin secretagogue- forces the pancreas to release more insulin
-IDE suffix Ex) glipizde-Glucatrol, glyburide-Diabeta, glimepiride-Amaryl (most potent and $4.00) must adjust dose in renal impairment *** sulfonamide alllergy less effective in older years b/c beta cells are less functional and less likely to respond |
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What is a biguanide?
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Reduces hepatic glucose production and intestinal glucose absorption, insulin sensitizer via increased glucose uptake and utilization.
less GI upset if take with meal risk of lactic acid build up with hypovolemia monitor creatinine, DO NOT give with impaired renal function. avoid in heart failure. Stop glucophage before IV contrast > 48 hours before |
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What are the thiazolidinedione, TZD or glitazone?
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Insulin sensitizer at receptors found in muscle adipose and tissue.
Risk of liver toxicity. Actos and Avandia (glitazones) Risk for edema and may exacerbate heart failure. $$$$$$$ |
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What are the incretin mimetics?
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Injection only, stimulates insulin production in response to increased plasma glucose. Slows gastric emptying.
ex-Byetta-exenatide use after other orals fail to improve risk of pancreatitis caution in renal impairment |
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What are the dipeptidyl peptidase inhibitors? DPP-4
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causes increased levels of incretin which cause release of insulin from beta cells and decreases release of glucgon from pareatic cells
careful in renal use in combo with glucophage or TZD pancreatitis risk ex- Januvia-stiagliptin |
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What are the meglitinides?
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Short acting insulin secretegogue, increases insulin secretion
ex- prandin-repaglinide take 30 min prior to meal quick burst of insulin within 20 minutes "covers a meal" |
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what are the alpha-glucosidase inhibitors?
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they delay carb absorption by reducing digestion of straches
+ GAS take them with first bite of meal carbs break down over 3 hours instead of one ex- Acarbose-precose |
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What are the amylin analogs?
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injection only
changes gastric emptying helping post prendial sugars, increased feeling of fullness resutls in decreased calories and weight loss. HYPOGLYCEMIA risk. Can only use iwth meal > 250 calories ex- pramlintide-Symlin |
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What is incretin?
|
hormone that stimultes the beta cells to secrete insulin
careful with incretin and workload it puts on pancreas |
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How do you go about treating a patient with type 1 DM?
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Treat all patients with a basal insulin with adjustments for meals.
Example- The pumps delivers insulin at a basal rate. Pancreas secretes 50% basal insulin and the other 50% in response to meals. Want to mimic this with insulin therapy. |
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Are there any contraindications to insulin?
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No it's bioidentical to human form
|
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What is the onset, peak and duration of lispro-Humalog
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Onset- 15-30 minutes
peak - 30min-2.5 hrs duration- 3-6.5hrs RAPID |
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What is the onset, peak and duration of Aspart-Novolog?
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Onset - 10-20 minutes
peak - 1-3 hours duration - 3-5 hours RAPID |
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What is the onset, peak and duration of insulin glulisine-Apidra?
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Onset - 10-15 minutes
peak - 1-1.5 h duration- 3-5 h |
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What is the peak, onset and duration of regular insulin?
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Onset - 30 minutes -1 hour
peak- 2-3 hours duration- 4-6 hrs |
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What is the peak, onset and duration of NPH-novalinN, Humilin N?
|
Onset - 1-2 hrs
peak - 6-14 hrs duration- 16-24 hrs use as basal insulin INTERMEDIATE |
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What is the peak, onset and duration of glargine insulin-Lantus?
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Onset -1 hour
peak -none duration- > 24 hours LONG ACTING |
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What is the onset, peak and duration of detemir insulin-Levemir?
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Onset - 1-2 hrs
peak - 6-8 h duration- 12-20 hrs LONG ACTING |
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How do you treat new onset DM?
|
insulin and oral medication
2 weeks of intensive insulin (basal and meals) Accucheck QID |
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What are additional care measures to consider using in DM?
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ASA or ACE
BB Cholesterol Meds (goal LDL<100 and HDL > 45 Diet Exercise and eye care Foot care Goals, review then periodically |
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Can you use Plavix if you have an ASA allergy?
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Yes. 75 mg/day
|
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What is the earliest sign of deteriorating renal function?
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Microalbumin
early warning system as early as 10 years |
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What is the recommended physical activity for DM?
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150 min per week
>30 minutes 5 x week resistance exercise > 3 x week |
|
What is the difference between proliferative and non-proliferative retinopathy?
|
Non occur before and there are no new vessels. Usually progresses to proliferative, where you see new vessels on the retina.
See cotton wool spots |
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Which side of the heart has a lower pressure?
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Right
allows for venous return |
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Which side of the heart has increased pressure?
|
left side
the left atrium is the highest |
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What side of the stethoscope do you hear high pitched sounds
|
diaphragm
low pitched with bell |
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What happens during S1?
|
Beginning of systole
Mitral and tricuspid close lub PULSE |
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what happens during s2?
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heart at rest and it gets perfused.
Closing of aortic and pulmonic valves |
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What is physiological splitting?
|
The widening of interval between aortic and pulmonic components of the second heart sound. Caused by the pulmonic component. Heard best in pulmonic region.
INCREASES ON INSPIRATION. Benign |
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Where is the apex of the heart?
|
Bottom
|
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What is pathological splitting?
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A fixed split that does not change with inspiration. It may narrow or close with inspriation. Heard in pulmonic region.
Usually from septal defect. If paradoxical then may be LBBB. |
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What is S3?
|
Ventricular overload or systolic dysfunction. Heard early in diastole, as if it's hooked on the back of s2.
Hear it with Bell. |
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What is S4
|
Marker of poor diastolic function. Poorly controlled HTN or recurrent MI. Sounds more like it's hooked on to s1. Sometimes called a presystolic sound. Best heard with bell.
|
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What is an incompetent valve?
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failure to close adequately.
Refers to regurg. The valve does not close therefore will regurg back. |
|
What kind of murmur are pathological, systolic or diastolic?
|
DIASTOLIC are always pathological
|
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What are the systolic murmurs?
|
Mitral
Regurgitation Physiological Aortic Stenosis Systolic Mitral Valve Prolapse |
|
What are the diastolic murmurs?
|
Mitral
Stenosis Aortic Regurgitation Diastolic |
|
What is mitral reguritation?
|
systolic murnur
holosystolic (same volume all the way throughout systole) radiates to axillary area |
|
If it radiates to the neck what kind of murmur is it?
|
Aortic
|
|
What is aortic stenosis?
|
crescendo-descrscend murmur that sounds harsh
occurs during systole picture a diamond <> |
|
What is mitral valve prolapse?
|
a midsystolic murmur
|
|
What is mitral stenosis?
|
late diastolic murmur that sounds like a rumble
bowling ball going down gutter |
|
What is aortic regurgitation?
|
early diastolic murmur, blowing sound
|
|
What is a Still's murmur?
|
benign
see with this 3 y/o boys sound like a cell phone on vibrate |
|
How do you grade a murmur?
|
1- faint
2- quiet but quickly heard 3- moderately loud, no thrill 4- loud thrill 5- very loud with thrill 6- hear without scope |
|
if a murmur softens or disappears when going from supine to standing it is most likely benign or pathological?
|
Benign
the heart widens up with the movement this is the same as the squat eval |
|
If a murmur increases with intensity when changing from supine to standing is it benign or pathological?
|
Pathological
consider IHHS |
|
What murmur is systolic and loud?
|
Mitral regurgitation.
holosystolic. Radiates to axiallae |
|
Who has the highest risk for bacterial endocarditis?
|
1- prothetic valves
2- past hx of endocarditis |
|
What murmur is a crescendo decrscendo murmur?
|
aortic stenosis
calcification present that prevents outflow= DOE hear it in neck |
|
What is IHHS?
|
Ventricular hypertrophy, when stand ventricles butt up against each other and there is less blood flow in the heart
from hypertrophy and overgrowth of muscles |
|
increased pulse pressure = increased peripheral vascular resistance... true or false?
|
True
BP= Hr x SV X PVR Pulse pressure = systolic- diastolic |
|
What are the target organs for HTN?
|
Brain- CVA, dementia
Cardio- atherosclerotic, MI, hypertrophy, CHF Kidney- failure and nephropathy eye- retinopathy and blindness |
|
What is the most common cause of left ventricular hypertrophy?
|
HTN
|
|
When will you see creatinine rise in kidney failure?
|
When 50% damaged
first sign is proteinuria |
|
What changes will you see with HTN retinopathy
|
narrowing of terminal branches then eventually vessels, hemorrhage in retina, and permanent findings then ICP leads to papilledema
|
|
Stage 1 HTN
|
140-159
90-99 |
|
Stage 2 HTN
|
>160
>100 |
|
What are the goals of HTN?
|
Avoid target organ damage.
non-DM <140/<90 DM and renal disease <130/<80 renal disease with proteinuria 1g/24hrs <125/<75 |
|
What are the lifestyle modifications for HTN?
|
Weight reduction (BMI 18.5- 24.9)
DASH eating plan Dietary sodium reduction (2.4 g) aerobic activity moderate ETOH consumption: men< 2/day women < 1/day |
|
What is the primary use for loop diuretics?
|
Volume reduction
as with CHF |
|
How do you treat stage 1 HTN without compelling indications?
|
Thiazide for most.
Consider ACE, ARB, BB, CCB or combo |
|
How do you treat stage 2 HTN without compelling indications?
|
2 drug combo for most
Thiazide plus and ACE, ARB, CCB or BB |
|
How do you treat HTN with compelling indications?
|
Diuretics, ACE, ARB, BB, CCB as needed
|
|
What are the thiazide diuretics?
|
HCTZ-hydroDiuril, chlorthalidone-Hygroton.
Causes low volume sodium depletion that leads to decreased PVR. WIll increase lipoprotein Good for women with osteo increased insulin resistance NA, MG and K depletion possible (spars CA) less effective with renal impairment--> use loop |
|
What are the beat blockers?
|
-olol group
Caution with COPD, asthma and heart block worsens insulin resistance and may mask hypoglycemia to discontinue taper dose these meds work by blunting the catecholamine response to decreased HR and stroke volume |
|
What are the alpha-beta adrenergic blockers?
|
Alpha adrenergic blockers
use caution with COPD, asthma and heart block work by blunting catecholamine response Carvedilol-Coreg, labetalol-trandate |
|
B1 is the -----------
B2 is the --------- |
(one) heart
(two) lungs |
|
What are the ACE inhibitors?
|
-pril group
risk of angioedema hyperkalemia risk cough common side effect Cat D in pregnancy NEVER USE WITH BILATERAL RENAL ARTERY STENOSIS works by blocking angiotensin II which is a super powerful vasoconstrictor--> decreased PVR |
|
What are the ARB's?
|
Angiotensin recpetor blockers
works like ACE no risk for angioedema no cough ex- cozaar, lorsartan, telmisartan-Micardia SARTAN K+ sparring, risk of hyperkalemia |
|
What are the direct renin inhibitors?
|
Aliskiren-Tekturna
$$$$ similar to ACE risks |
|
What are the calcium channel blockers?
|
POWER HOUSES
-ipine suffix amlodipine-Norvasc, felodipine-Plendil nonDHP ones are cardiazem, and verapimil WORK BY CAUSING VASODILATION! risk for edema CYP450 renal protective non-DHP's caution with >1st degree heart block avoid in heart, renal or liver failure |
|
What are the aldosterone agonists?
|
Spironolactone (Aldactone)
blocks aldosterone and regulates sodium and water better risk for hyperkalemia gynecomastia K sparring tx hirsutism leads to decreased peripheral vascular resistance |
|
What are the alpa adrenergic antagonists?
|
AZOSIN group
terazosim-Hytrin, doxazosin-Cardura causes vasodilation and therefore decreased PVR should not use as solo drug helpful in prostatism |
|
What are the centrally acting agents for BP/HTN?
|
Clonidine-catapres, methyldope-aldomet
Work at center of brain for BP control risk for sedation DO NOT ABRUPTLY WITHDRAWAL |
|
What are the direct vasodilators?
|
Hydralazine-Apresoline, minoxidil
peripheral vasodilation by relaxing the smooth muscle risk for sedation "tired and hairy" may cause drug induced Lupus(hyralasize) tx hirsutism with monoxidil |
|
What is chlorthalidone?
|
diuretic, thiazide
causes increased sodium secretion therefore water goes with it DO NOT USE IN GOUT CAN PRECIPITATE ATTACK-will increase levels of uric acid |
|
When must you do a fasting lipid profile?
|
Those with significant cardio risk and those with elevated non fasting levels
|
|
What is the goal for LDL?
|
<160 if no risk factors
<130 if 1 risk <100 with CHD or DM <70 if high risk |
|
What is the goal for HDL?
|
>60 in women
|
|
what is the goal for total cholesterol?
|
< 200
200-230 borderline high >240 high |
|
What are the lifestyle modifications for cholesterol?
|
increase fiber, decreased fat intake, increase omega fatty acids, lose weight, activity
|
|
What are the HMG Co Reductase inhibitors?
|
STATINS
powerhouse LDL reducers watch liver CK, rhabdo grapefruit juice will increase effect!!!!!!!!!!!!! |
|
What are the bile acid resins?
|
Sequestrants- Qustran-cholestyramine, Welchol
DIARRHEA lower LDL binds to comadin and renders it ineffective works by sitting in gut absorbs bile acid and therefore decreases cholesterol |
|
What is Zetia?
|
ezetimibe
selective cholesterol inhibitor works in the lumen of the gut and blocks the absorbance of cholesterol few systemic effect due to limited absorption |
|
How does niacin work?
|
lowers lipoprotein
FLUSHING- minimize by taking ASA contraindicated in gout, lever disease and peptic ulcer |
|
What are the fibric acid derivatives?
|
Tricor,fenofibrate
dypepsia, gallstones, myopathy and rhabdo not with renal or hepatic disease |
|
How does fish oil work?
|
Lower tirglycerides, GI upset, increased risk of bleeding due to modest antiplatelet effect
discontinue 10 days prior to surgery |
|
How does red yeast work?
|
This is what statins are derived from. Stop cholesterol synthesis. Same risks as statin- rhabdo.
CYP450 no grapefruit juice and some macrolides lowers LDL |
|
Do ace inhibitors cause hypertriglyceridemia?
|
No, will raise HDL and lower tri's
also insulin sensitizing |
|
What is a therapeutic INR?
|
2-3
normal - 1-2 |
|
At what tanner stage does menarche occur?
|
4
|
|
What has a fishy odor on KOH whiff test?
|
BV
|
|
What has pseudohyphae on KOH test?
|
yeast, candidia
|
|
What has gray discharge?
|
BV
|
|
What has clue cells
|
BV
|
|
How to you treat trichomonasis?
|
Metro one time large dose (2 g)
|
|
What is the most common cause of penile discharge?
|
Gonorrhea
irritative voiding symptoms rocephin use spectinomycin if have beta lactam allergy |
|
What is the cause of non-goncoccal urethritis/cervicitis?
|
C. trachomatis, ureaplasma, mycoplasma
tx- zithromax 1g dose |
|
What is the cheapest med to tx herpes with ?
|
acyclovir
valtrex is much more expensive |
|
What has green yellow frothy discharge?
|
Trich
alkaline pH |
|
What is the pH in atrophic vaginitis?
|
alkaline- the most alkaline
tx with estrogen |
|
How do you treat PID?
|
roceph+doxy or zith
with or without metro (when suspect anerobes as source) |
|
What can you treat with clindamycin cream?
|
BV
|
|
With what do you see strawberry hemorrhages on the cervic?
|
Trich
|
|
What do you suspect in candida infection in males?
|
HIV, DM
this is not normal tx with topical |
|
What is G6PD?
|
enzyme deficiency resposible for RBC synthesis
RBC start to hemolyze with a lot of different medications X linked painless jaundice MUST RX Non-oxidative drugs (ex cefixime is safe) |
|
Most common organism in UTI?
|
E. coli (g-)
S. saprophyticus (g+) Enterococci (g+) |
|
How do you treat a UTI?
|
Bactrim: if unlikely resistant E. coli
If resistant or sulfa allergy: CIPRO, LEVO nitrofurantonin as well (safe in preg not 3rd tirmester) |
|
How do you treat pyelonephritis in out pt setting?
|
Cipro
levo for a week |
|
What is test result is most sensitive to g- bacteria in urine testing?
|
nitrite and leukocyte esterase
|
|
What does a boggy prostate indicate?
|
prostatitis
|
|
What will you see with BPH?
|
obilterated median sulcus, enlarged prostate, sensation of incomplete emptying of bladder
|
|
What do you tx epididymitis with?
|
if , 35 y/o most common cause is gonorrhea or chlamydia- tx with roceph and zith
if > 35 most common cause is enterobacteriaceae. tx with cipro presents with irritative voiding s/s, painful and swelling to scrotum, infertility possible post infeciton |
|
How do you tx acute bacterial prostatitis?
|
same as epididymitis.
<35 roceph and zith > 35 cipro will present with fever, voiding s/s, perineal pain, boggy prostate |
|
if you have treatment failure when treating prostatitis, what should you suspect?
|
prostate stones- need a long course of cipro
|
|
What is the most common finding with bladder cancer?
|
painless gross hematuria
you may see persistent microscopic hematuria |
|
Should the ovaries be palpable on a post menopausal woman?
|
Nope.
|
|
What is a hydrocele?
|
colleciton of serous fluid that causes painless scrotal swelling easily seen by transillumination
|
|
What is a varicocele?
|
bag of worms
scrotal mass that in only evident in standing position tx; jock strap and sx |
|
what is characterized by the loss of the cremasteric reflex?
|
testicular torsion
|
|
What is phimosis?
|
Can not pull the foreskin back to expose glans
|
|
What is paraphimosis
|
can not replace foreskin to cover the glans
|
|
What is cryptorchidism?
|
testicle located in the inguinal canal or abdomen
undescended assoc. with increased risk for CA |
|
When should antiretroviral therapy be started in HIV/AIDS?
|
CD4 of 350 or less
and initiate regardless is pregnant, hep B, or nephropathy |
|
Should pt's go on and off antiretrovirals?
|
NO- will create resistance
commitment is lifelong |
|
If have PCP and HIV when should u start antiretrovirals?
|
ASAP, no delay
|
|
Which medication is preventative for gout
|
Allopurinol
|
|
Is colchicine for acute or preventative?
|
Acute
|
|
What route is most common for Hep A
|
fecal oral
|
|
What route is most common for tranmission of Hep B
|
blood and body fluids
|
|
What route is most common for transmission of Hep C
|
Blood, body fluids- NO vaccine
|
|
Ig G blood testing means what if positive?
|
It's GONE
|
|
IgM testing means what if it's positive?
|
You have it now and are MISERABLE
|
|
IgM testing means what if it's positive?
|
You have it now and are MISERABLE
|
|
What are the major differences between delirium and dementia?
|
Delirium- sudden, hours to days, potentially reversible, change in psychomotor activity
Dementia- progressive, months to years can coexist, should consider delirium when there is a sudden change |
|
What is the leading cause of delirium in an older adult?
|
Infection. Older adults not good at localizing infection.
|
|
What type of head injury/bleed can result from minor head trauma?
|
Subdural hematoma.
Due to a combination of brain atrophy and relatively fragile vessels in the elder |
|
What is the difference between dementia and depression in the older adult?
|
Depression is rapid, they are oriented, difficulty concentrating but not usually with memory.
|
|
What is the most common type of dementia?
|
Alzheimer type
|
|
How do you treat early Alzheimer's?
|
Want to slow the decline
Vitamin E Selegeline (MAO inhibitor) Aricept-donepezil, cholinesterase inhibitor (increases acetylcholine, only works on live neurons so want to start early to prolong progression of disease) Namenda-memantine, creates an environment that allows for storage and retrieval of information |
|
What are some side effect of risperdal-risperdone?
|
Weight gain
increased insulin resistance increased blood clots --> increased stroke and cardiac events |
|
Can a cholinesterase inhibitor improve mental status?
|
Yes. May return to pre-demetia baseline
|
|
What are the signs of a major depressive episode?
|
Sleep disturbances, interest decreased, guilt, energy, concentration, appetite, psychomotor, suicide
SIGECAPS |
|
What are the goals in the treatment of mood disorders?
|
Prevent relapse
virtual elimination of symptoms |
|
When should ECT be considered?
|
Major depressive disorder with high degree of symptom severity and functional impairment
- in cases with psychotic symptoms and catatonia -need an urgent response, suicidal or refusing food |
|
Which SSRI is the most energizing?
|
Prozac-fluoxetine
|
|
Which SSRI has the longest half life?
|
Fluoxetine-Prozac
|
|
Which SSRI has anticholinergic effect?
|
Paroxetine-Paxil
|
|
Which SSRI has the least interactions?
|
Escitalopram-Lexapro
Citalopram-Celexa Paxil and Prozac have the most interactions |
|
Which meds are better to use with anxiety, SSRI or SSNRI?
|
SSNRI
helpful in anxious depression reports of being energized |
|
Which psych med is the worst to OD on?
|
TCA's- nortriptyline and amytriptyline
Prolonged QT- cardiac arrest and seizure |
|
If a pt is likely to miss a dose of SSRI, which med will be better for them?
|
Prozac-fluoxetine, long half life so no withdrawl
|
|
What is the best way to differentiate between septic arthritis and and gout?
|
Joint aspirate
will see crystals with gout |
|
Is the main problem with gout overproduction of uric acid or undersecretion?
|
undersecretion
worsens with renal insufficiency, ETOH, diuretics and ASA they don't secrete enough uric acid |
|
What foods should those with gout avoid?
|
high purine
sweetbreads, liver, sardines, anchovies, kidney |
|
When testing the bicep reflex you are checking what?
|
c 5&6
|
|
When testing the tricep reflex you are checking what?
|
c7
|
|
When testing the brachioradialius reflex you are checking what?
|
c6
|
|
When testing the patellar reflex you are checking what?
|
L4
|
|
When testing the achilles reflex you are checking what?
|
s1&2
|
|
What is clonus?
|
oscillations
|
|
What is the McMurray test?
|
for meniscal tear
|
|
What is the Talar tilt test?
|
ankle instability
|
|
What is the Spurling test?
|
cervical nerve root compression
|
|
What is the tinel's test?
|
carpal tunnel
tap on wrist |
|
What is the Lachman test?
|
like anterior drawer test but on an angle
check for ACL tear |
|
What is the Straight leg raise test?
|
lumber nerve root compression
|
|
What is the drop arm test?
|
rotator cuff injury
|
|
What is the finkelstein test?
|
DeQuervian tenosynovitis
|
|
What is Osgood-Schlatter disease?
|
during growth spurt
swollen tibal tuberosity pain with movement tx with decreased activity The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity. Following an adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity. This can cause multiple subacute avulsion fractures along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful when hit. |
|
Characteristics of Lumbar sacral strain
|
Normal neuro exam
spasm, ache and stiffness |
|
What is the muscle relaxer with greatest risk of sedation?
|
Soma=Coma
greatest risk for abuse |
|
Characteristics of lumbar radiculopathy?
|
Most common site L4 L5 S1 (bulging disc)
sharp electric shock sensation sneeze, cough and strain evokes sharp pain +Straight leg raise altered DTRs |
|
What is Pagets disease?
|
Paget's disease of bone, the rate at which old bone is broken down and new bone is formed becomes distorted. Over time, the affected bones may become fragile and misshapen.
|
|
When do you get and MRI or CT with back pain?
|
Persistent lower back pain with s/s of radiculopathy or spinal stenosis
also if candidate for sx or corticosteriod injections |
|
Dorsifelxion innervates what?
|
L5
|
|
What is an important characteristic of spinal stenosis?
|
pain unilateral, common with agina, pseudoclaudiculation
worse when you stand or walk lessen or disappear when you sit down or lean forward cannot walk for a long period of time. Spinal stenosis is narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. s/s > 1 month = MRI |
|
What is the most helpful intervention to minimize hip fracture in an older woman?
|
Aldendronate use (Fosamax)
biphosphonates give with vitamin D and calcium treat early to minimize damage |
|
Osteopenia is defined as how many standard deviations from the normal?
|
1-2.5 on DXA scan
checked in spine, hip or forearm 1 SD is ok Osteoporosis is 2.5 SD treat at 1-2.5 |
|
Who should be tested for osteoporosis?
|
women >65, man >70
those with increased risk factors: post HRT therapy, smoker, diease presence, family hx etc |
|
What will you see on xray with osteoarthritis?
|
Narrowing of joint space
|
|
Signs of osteoarthirtis
|
hypertrophic joint
Bouchard-PIP Heberden- DIP |
|
What is ankylosing spondylitis?
|
Joint b/w spine and pelvis fuse
+ pain with inactivity decreased pain with movement in the scaroilliac jointsbegins between ages 20 and 40 |
|
What are some lifestyle modifications for GERD?
|
raise HOB
lose weight stop smoking limit ETOH, fatty and other offending foods eliminate some meds- CCB, nitrates and theophylline |
|
What are the meds for GERD
|
anatacids- all metals, immediate acid neutralization (careful will chelate other meds) THESE ARE SUPERIOR
H2 blockers- pepcid , zantac IDINE (avoid tagamet b/c drug interections) PPI-Nexium,protonix AZOLE |
|
Which medication is most effective against duodenal ulcer?
|
Antibiotics- most commonly caused by H.pylori
otherwise ulcers with heal and then come back so you need to irradicate it flagyl biaxin and amox |
|
What is Cullen's sign
|
ecchymotic areas noted in the periumbilical region caused by retroperitoneal and intraperitoneal blood leak
"ecchymosis from the inside out" Ectopic or hemorrhagic pancreatitis |
|
What is Markle's sign
|
stand on tip toes and let body weight fall quickly onto the heels
+ if abd pain increases and suggestive of perotineal inflammation |
|
What is blumberg's sign
|
elicited by deeply palpating an area of abd tenderness and tehn rapidly releasing the pressure
pain is worse with release usually indicating abd wall or perotineal inflammation known as rebound tenderness |
|
What is murphy's sign
|
Painful arrest of inspiration triggered by palpating the edge of inflamed gallbladder
|
|
What should you suspect if vomiting and fever occur at the onset of abd pain?
|
Gastroenteritis
infection hits the gut at the same time |
|
What are obturator and psoas signs
|
seen with perineal inflammation
move those muscles to elicit the pain |
|
Characteristics of erosive gastritis?
|
NSAIDS
pain worse after eating (get huge acid surge) disease of too much tender LUQ and hyperactive bowel sounds |
|
Characteristics of acute pancreatitis
|
ETOH use
epigastric pain that radiates to back with bloating (distention because gut is not working so well) |
|
Characteristics of duodenal ulcer
|
pain is worse when tummy is empty, therefore pain is decreased after eat
|
|
Characteristics of diverticulitis
|
LLQ pain
fever, cramping, and loose stoos |
|
Characteristics of Inflammatory bowel disease -crohn and ulcerative colitis
|
crampy abd pain, diarrhea, weight loss and fatigue, tenesumus, sometimes fever
pale, tachy, diffuse abd tenderness long hx of problem |
|
Characteristics of acute cholecystitis
|
RUQ pain with radiation to shoulder, pain improved with vomiting, no fever
|
|
Difference b/w crohn and ulcerative colitis
|
Crohn goes from mouth to anus with cobblestone appearance
Colitis only in colon |
|
what is the normal hepatic span
|
7 cm at midclavicular line on right
|
|
What does it mean if HBsAG is present
|
Hep B present
if HBsAB- means you have antibodies to it from past infection or immunization |
|
Is there a risk for cancer with hepatitis
|
Yes. Hepatocellular carcinoma with hep B or C
|
|
who should not use and IUD?
|
PID
cerivcitis unexplained bleeding cervical CA fibroids with distorted uterus +antiphospolipids |
|
When should you test for DM in child?
|
Tanner 2 onset of puberty or about 10 years
consider the risk factors |
|
What conditions make a teen emancipated for medical treatment
|
smoking cessation
birth control and pregnancy std treatment |
|
Which is more serious rubella or rubeola?
|
rubeola, 10 days measles
rubella, is 3 day or german measles |
|
Differences between rubella and rubeola
|
rubella- 3 days, longer incubation 14-21 days, mild and self limiting, posterior cervical lymphadenopathy prior to rash
rubeola- lasts 10 days, incuation 10-14 days, CNS and respiratory complications Both transmissible for a week prior to rash and 2-3 weeks after rash, both treated with supportive care |
|
What do you want to tx kawasaki's with ?
|
ASA and IgG to reduce cardiac abnormalities (dilation and aneurysm
|
|
When is the uvula deviated
|
Peritonsillar abscess
|
|
characteristics of epiglottis
|
rare, steeple sign, often caused by H. influenzae in children 2-7
abrupt onset with high fever and drooling |
|
What infants need iron supplementation
|
preterm, those fed milk/breast milk (1 mg/kg/day started at 4 months until iron fortified foods are introduced)
do not need with formula |
|
what murmur obliterates the heart sounds
|
mitral regurgitation
|
|
What is stridor?
|
Inspiratory wheeze, problem is getting air in as opposed to out with a expiatory wheeze
most often in kids |
|
With what do you see a hot potato voice
|
PTA
also have trismus |
|
Can you give trimaminec to kids
|
no pulled from shelves
5 deaths from this |
|
Can you give fluoroquinolones to kids
|
nope
issue with growth plates |
|
What does an effusion mean in AOM?
|
fluids behind the ear
usually from eustachian tube dysfunction should only be air behind drum, no fluid |
|
What is bullous myrngitis
|
painful
the surface of TM ruptures (not the TM) be sure to give topical pain agent |
|
How to you distinguish a severe otitis vs. non
|
fever > 102.2
treat with sever, may watch with non b/c high rate of spontaneous resolution without meds always treat if you can not follow up |
|
what are the components of AOM
|
bulging TM, erythema, no mobility, air-fluids level behind ear
purulent drainage |
|
Most likely pathogen in AOM
|
s. pneumoniae
|
|
What is OME
|
otitis media with effusion, there are no signs of infection only effusion (fluid in the middle ear)
75-95 resolve without tx if have persistent and language delay-->tympanostomy |
|
What is a hemiangioma
|
vascular lesion, likely ill increase in size over first year of life
watch and wait, maybe steroids, sx laser |
|
what is a port wine spot
|
grows proportionately with child, like a birth mark
|
|
What is erythema neonatorium toxicum
|
common and benign fluids filled lesions loaded with eopeinophils, reassure parents
|
|
What are milia
|
on sebaceous area after birth
|
|
When does neonatal acne appear
|
3-5 weeks after birth
|
|
Can you palpate a mongolian spot
|
no, they are non-tender as well
blue black patches |
|
Common site for eczema in babies
|
face, no so common when older
|
|
If a baby has a fever, when do they get a sepsis work up
|
<1 month old-->ADMIT
pale, decreased cap refill, lethargic, irritable, not clinging to parent, tachy, no fluid food toleration, want to see they viod every four hours |
|
what is pleocytosis
|
WBC in CSF
consistent with viral or bacterial meningitis |
|
What is the clinincal presentation of lead poisoning
|
none, few symptoms if any
if severe poisoning will have anorexia, constipation, and recurrent abd pain tx: chelation if lead levels > 45ug/gl |
|
Who is at greatest risk for lead poisoning?
|
2-3 y/o
consider if < 6 Those who live in house with lead based paint, built prior to 1957, also increases risk with renovation of these homes toys from unregulated sources in latino folk meds chinese meds to calm fussy kids candy from mexico |
|
what are normal lead values
|
0-9.9ug/dl
no level is considered safe if get a + repeat and confirm testing, repeat test sooner if high levels (10=1-3 mo, 15=1-2 mo, 20= 1 wk, 45= 1 week) > 70 medical emergency hospitalize and repeat test immediately |
|
When is post partum depression most common?
|
2-4 months post preg, but can occur any time within 1 st year
|
|
When does post partum psychosis occur
|
3 days
may need to hospitalize due risk for harm (baby and mother) |
|
Do older adult have increased or decreased serum albumin
|
decreased
|
|
What kind of half life do you want in elder
|
shorter the better
go low and go slow |
|
what happens to CYP450 with age
|
CYP450 isoenzymes drop in older
|
|
Does GFR increase or decreased with age
|
decrease
|
|
What is true about nitrofurantoin and elders
|
careful because with decreased Creat clearance you will not get an adequate concentration and treatment may fail
others-Januvia no antimicrobial adjustment with rosh, doxy clinda moxy |
|
What is true about elders and cholinesterase inhibitors
|
increased risk for cardia event (aricept)
|
|
What is preterm
|
<37 wks
|
|
most accurate measurement of baby
|
crown rump- most accurate dating, done in 1st trimester
|
|
what size is fetus at 8 weeks
|
tennis ball or orange
|
|
what size is fetus at 10 weeks
|
baseball, FHT with doppler possible in thin
|
|
what size is fetus at 12 weeks
|
grapefruit
|
|
what size is fetus at 16 weeks
|
halfway between syphsis and umbillicus
|
|
what is thiamine deficiency
|
b1
seen in ETOH Wernecke=korsakoff |
|
what is folic acid deficiency
|
b9
anemia there is plenty of folic acid in green veggies neural tube defects |
|
What do you see with vit. k deficiency
|
clotting disorders
also used to reverse excessive coagulation (reverse coumadin) |
|
What effect do antidpressants have most on depression
|
allevating sleep disturbances and helping with appetite
|
|
What is the most common cause of dementia
|
alzheimers and vascular disease
|
|
What valerian root
|
anxioltic and sleep aid
herbal |
|
What are some mediations that have depression as a side effect
|
antiparkinsons, hormones, htn meds
|
|
What are the s/s depression
|
Sleep
intertes guilty energy concentrate appetite psychomotor |
|
What is a thymectomy
|
Removal of thymus
therapeutic in myesthenia gravis |
|
What are some medications use in Myethenia gravis
|
cholinesterase inhibitors-neostigmine
immunosuppresives |