AANP Exam study guide to Family Nurse Practioner FNP - digital item/FNP Review.

PREVENTION/HEALTH PROMOTION/IMMUNIZATION

LEVEL OF PREVENTION ➢

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PRIMARY o Goal: preventing the health problem, the most cost-effective form of healthcare o Example: immunizations, counseling about safety, injury and disease prevention SECONDARY o Goal: detecting disease in early, asymptomatic, or preclinical state to minimize its impact o Example: screening tests, such as BP check, mammography, colonoscopy, ASA in hx MI TERTIARY o Goal: minimizing negative disease induced outcomes o Example: in established disease, adjusting therapy to avoid further target organ damage.

Potentially viewed as a failure of primary prevention, support groups

IMMUNIZATION PRINCIPLES ➢

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Community (herd immunity) o Immunize those who can be to protect those who cannot be immunized Active immunity o Resistance developed in response to an antigen (either infection or vaccine) Passive immunity o Immunity conferred by an antibody produced in another host (infant of mother or immune globulin

Immunize unless sending to the hospital in an ambulance

IMMUNIZATION PEARLS HX of Anaphylactic reaction Neomycin Streptomycin, polymyxin B, neomycin Baker’s yeast Gelatin, neomycin Gelatin

Immunization to avoid

Number of packs-per-day (PPD) Multiplied by # of years smoked

IPV, MMR, varicella IPV, smallpox

5 A’S OF SMOKING CESSATION Hepatitis B Varicella zoster MMR

Previously unvaccinated adults age 19-59 with diabetes should be vaccinated against Hepatitis B

LIVE VACCINES o

SMOKING - PACK YEAR HX

1. Ask about tobacco use 2. Advise to quit 3. Assess willingness to make a quit attempt 4. Assist in quit attempt 5. Arrange follow-up

MMR ▪

Patients born before 1957 have likelihood of immunity due to natural infection ▪ Two doses 1 month apart for those never immunized o Varicella o Zostavax o Intranasal Flu Mist ➢ Avoid these with Pregnancy, immune suppression and with HIV (CD4 count < 200) – case by case situation ➢ Rotavirus o Avoid with SCID (severe combined immunodeficiency)

HEPATITIS B ➢ Chronic Hep B can lead to hepatocellular carcinoma, cirrhosis and continued infectivity ➢ Childhood Hep B vaccines began in 1982 ➢ 3 dose series 0, 1, 6 months ➢ If not vaccinated and exposed – HBIG and series ➢ If vaccinated and exposed – single dose vaccine

PNEUMOCOCCAL IMMUNIZATION ➢ PCV13 associated with greater immunogenicity ➢ PPSV23 not licensed for children under 2 ➢ Indications: chronic lung disease, chronic cardiovascular disease, diabetes, chronic liver disease, chronic alcohol abuse, smokers, malignancy, chronic renal failure, asplenia, sickle cell, immunocompromised, HIV. ➢ PCV13 followed by PPSV23 one year later and then again at 65 o Exception: HIV (8 weeks later) ➢ If PPSV23 before age 65, repeat in 5 years

PREVENTION/HEALTH PROMOTION/IMMUNIZATION

TETANUS SMALLPOX ➢ Caused by variola virus ➢ Infective droplets – contagious during fever, but most contagious during rash o Contagious until last scab falls off ➢ Stopped vaccinating in 1972 ➢ Incubation period 7-17 days ➢ Prodromal stage – fever, malaise, headaches, body aches ➢ Rash starts on face > arms/legs > hands/feet o All lesions within same phase and spreads within 24 hours ➢ Vaccination within 3 days of exposure reduces severity ➢ Vaccinia – unique immunization method o 2-pronged needle dipped into vaccine and then pricks skin

POLIOVIRUS ➢ Transmission is fecal-oral

SENSITIVITY AND SPECIFICITY ➢ Sensitivity – ability of a test to detect a person who has disease (SEN rule in) ➢ Specificity – ability of a test to detect a person who is healthy (SPOUT – rule out)

VARICELLA ➢ Live virus; 2 dose series starting > 1 year of age ➢ Although highly protective, mild cases of chicken pox have been associated with the disease ➢ Varicella antibody titers should be ordered on a healthcare worker who had chicken pox as a child ➢ Varicella Zoster Immune Globulin (VZIG) is made of pooled blood product with excellent safety rating (given if contraindications for vaccine) ➢ Pregnant women without immunity should be vaccinated with two doses after giving birth ➢ Varicella is transmitted via droplet ➢ Vaccination within 3-5 days of exposure has shown benefits to reduce disease

STAGES OF CHANGE MODEL ➢ PRECONTEMPLATION o Not interested or minimalizes ➢ CONTEMPLATION o Considering change, looks at positive and negative, feels “stuck” ➢ PREPARATION o Exhibits some change behaviors, but does not have tools to proceed ➢ ACTION o Ready to go forward, takes concrete steps, but no consistency ➢ MAINTENANCE/RELAPSE o Learns to continue the change and embraced the healthy habit

➢ Infection caused by Clostridium tetani – found in soil lead to lockjaw ➢ If no previous immunity - give Tdap followed by Td in 1 and 6 months ➢ Need vaccine every 10 years with a single dose of Tdap in adulthood ➢ If dirty wound – BOOST if not TD in 5 years (Tdap and Immunoglobin if no previous vaccine)

HEPATITIS A ➢ Peak infectivity occurs the 2-week period before the onset of jaundice or elevated liver enzymes ➢ Approximately 50% of cases have no specific risk factors identified ➢ When traveling to developing nations, avoid foods that are eaten raw ➢ Administer 4-6 weeks prior to traveling to an area where disease is endemic ➢ Treatment is supportive

SHINGLES VACCINE ➢ Recommended for everyone except those contraindicated ➢ Infectious until lesions dry/crusted ➢ Zostavax o Live; One-time dose age 60 ➢ Shingrix o Non-live; 2 doses age 50 o Preferred vaccine

PREVENTION/HEALTH PROMOTION/IMMUNIZATION

US PREVENTATIVE SERVICES TASK FORCE ➢ Aspirin use to prevent cardiovascular disease and colorectal cancer o Age 50-59 with >10% ASCVD ➢ Breast Cancer o Mammography age 50-74 (every 2 years) o Risk factors (start age 40 or BRCA1/2) ▪ Previous hx of breast cancer ▪ >2 first-degree relatives ▪ Early menarche, late menopause, nulliparity ▪ obesity ➢ Cervical Cancer o Age 21 – screen every 3 years o Age 30 – screen with HPV every 5 years o Hysterectomy with removal of cervix – only need screening if hysterectomy due to cervical cancer o Stop screening at age 65 o Risk factors: ▪ Multiple sex partners ▪ Younger age at onset of sex ▪ Immunosuppression and smoker ➢ Colorectal Cancer o Start age 50-75 ▪ Colonoscopy every 10 years ▪ Flex sigmoidoscopy or CT colonography every 5 years ▪ FOBT (3 consecutive stool samples) annually ▪ New Cologuard o Risk Factors ▪ Familial polyposis ▪ First degree relative w/ colon CA ▪ Crohn’s (ulcerative colitis)

➢ Prostate Cancer o Benefits of PSA screening do not outweigh the disadvantages o Risk factors: ▪ Age > 50 ▪ African ancestry ▪ First degree relative ➢ Ovarian Cancer o Routine screening not recommended o BRCA1/BRCA2 mutations – refer to specialist ➢ Skin Cancer Counseling o Recommend for those with fair skin ➢ Abdominal Aortic Aneurysm o Men age 65-75 who have smoked o One-time ultrasound ➢ Lipid Disorders o Start low – moderate statin when all: ▪ Age 40-74 ▪ CVD risk factor ▪ ASCVD > 10% ➢ Lung Cancer o Smoke 30 pack-years or quit in last 15 years o Age 55-80 (annual screening with CT)

OVARIAN CANCER ➢ No recommendation for routine screening ➢ In postmenopausal women with palpable ovary o Intravaginal ultrasound and CA-125 ➢ Strongest risk factor is BRCA1 or BRCA2 ➢ Other risk factors include age, obesity, Clomid use or endometriosis ➢ Prostate/testicular cancer screening not recommended

CANCER PREVALENCE ➢ Skin cancer is most common cancer o Basal cell carcinoma o Melanoma highest mortality ➢ Men – prostate cancer ➢ Women – breast cancer ➢ Gynecological o Uterine/endometrial o Ovarian ➢ Children – acute lymphoblastic leukemia (ALL)

MORTALITY ➢ Leading cause of death (all ages) o Heart disease o Cancer ▪ Men (lung, prostate, colorectal) ▪ Women (lung, breast, colorectal) o Chronic respiratory

ADOLESCENTS ➢ Death rate for teen males is higher than females o Accidents (MVC most common) o Suicide o Homicide

PHARMACOLOGY

DRUG -DRUG INTERACTION

FIRST-PASS EFFECT

NARROW THERAPEUTIC INDEX DRUGS

➢ http://medicine.iupui.edu/clinpharm/ddis/clinical -table/

➢ Drug is swallowed and absorbed into small intestine where it enters portal circulation o Once in liver the CYP450 is responsible for biotransformation ➢ Drugs with extensive first-pass metabolism cannot be taken orally. o Insulin ➢ CYP450 can be induced (increase drug metabolism) or inhibited (slow down drug metabolism) o Biotransformation also includes kidneys, GI tract and lungs

➢ Warfarin – monitor INR o Sulfa drugs elevate INR o Interacts with “G” herbs o Mayonnaise and green leafy ➢ Digoxin – dig level, EKG, electrolytes (K+, Mg+, Ca+, Creatinine) ➢ Theophylline – monitor blood levels ➢ Tegretol and Dilantin – monitor blood levels ➢ Levothyroxine – monitor TSH ➢ Lithium – monitor blood levels, TSH

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Substrates: drugs that are metabolized as substrates by the enzyme o CYP450 3A4 substrates: Sildenafil, Atorvastatin, simvastatin, venlafaxine, alprazolam o CYP450 ↓ by 30% after age 70 ➢ Inhibitors: drugs that prevent the enzyme from metabolizing the substrates (↑ drug concentration) o Macrolides (Clarithromycin, Erythromycin) – can lead to substrate induced toxicity (Ex: atorvastatin 20mg may be like 300mg) o Antifungals (ketoconazole, fluconazole) o Cisapride (propulsid – no longer in US) o Cimetidine (Tagamet) o Citalopram (Celexa) o Grapefruit (statins, erythromycin, calcium channel blocker, antivirals, amiodarone, benzodiazepines, Cisapride, carbamazepine, buspirone) ➢ Activators: drugs that increase the enzyme's ability to metabolize the substrates (↓ drug) o St John’s wort - antiretrovirals, contraceptives and cyclosporine; Also lead to Serotonin syndrome when combined with SSRI, SSNI

SAFETY ISSUES NSAIDs ➢ Avoid in heart failure, GI bleeding, kidney disease o Inhibit prostaglandin synthesis – we need prostaglandins to keep things running smoothly o Long term use – document informed consent such as ↑ risk of MI, stroke, emboli, GI bleed, acute renal failure o Consider PPI, H2RA, Misoprostol

PHARM FACTS ➢ Pharmacokinetics – absorption, distribution, metabolism, elimination of a drug ➢ Pharmacodynamics – biochemical and physiological effects of drugs on the body or disease (this does not change as a person ages)

RANDOM FACTS ➢ Capsaicin cream can be used to treat pain in trigeminal neuralgia and post herpetic neuralgia ➢ ASA irreversibly suppresses platelet function for up to 7 days

➢ PPI - ↑ risk of fractures o Prilosec interacts with warfarin ➢ TZD – cause or exacerbate CHF ➢ Bisphosphonates – erosive esophagitis ➢ Statins – do not mix with grapefruit juice ➢ Clindamycin – high risk C. Diff ➢ Thiazide diuretics contraindication sulfa allergy o Chlorthalidone is longer acting and preferred over HCTZ ➢ Spironolactone can lead to gynecomastia ➢ DC ACEI/ARB if pregnant and are excreted in breast milk ➢ Alpha blockers are only first-line in makes with HTN and BPH

ANTIBIOTIC THERAPY ANTIBIOTICS GRAM POSITIVE

PRINCIPLES OF EMPIRIC ANTIMICROBIAL THERAPY ➢ Decision making process in which clinician chooses agent based on characteristics and site of infection ➢ What is/are the most common likely pathogen(s) causing this infection? ➢ What bug will this antibiotic kill? ➢ Likelihood of resistant pathogen? ➢ Danger if treatment failure? ➢ What is optimal safe dose? ➢ What duration is shortest but effective?

TETRACYCLINE ➢ Gram -; Atypicals; MRSA ➢ Do not use in pregnancy or children < age 9 ➢ May cause permanent discoloration of teeth and skeletal defects if used in last half of pregnancy ➢ Treat for acne age 13-14 as all teeth have erupted o Do not use for mild comedones – start with OTC topicals such as salicylic acid and benzoyl peroxide o Try RX topicals benzamycin, Retin A and azelaic acid cream first for 2-3 months ➢ Photosensitivity ➢ Esophageal ulcerations (swallow with full glass of water) ➢ Take on empty stomach ➢ May decrease effectiveness of birth control pills ➢ Throw away expired pills – they degenerate and may cause nephropathy

LINCOSAMIDE - CLINDAMYCIN ➢ Gram +, Aerobes, Anaerobes ➢ Associated with C. Diff

➢ Strep ➢ Staph ➢ Enterococcus

RISK FOR ANTIBIOTIC RESISTANCE ➢ Age <2 or >65 ➢ Antibiotic use within the last month o 3 months for pneumonia ➢ Hospitalization within 5 days ➢ Comorbidities ➢ Immunocompromised

GRAM NEGATIVE ➢ H. influenzae o Cephalosporin, Augmentin, macrolides, resp. fluoroquinolones, doxycycline ➢ Everything else

MACROLIDES ➢ Atypical pathogens ➢ Associated with potential QT prolongation and ↑ risk of CV death ➢ Contraindicated in myasthenia gravis ➢ Drug-drug interactions (anticoagulants, digoxin, theophylline, select statins) ➢ Erythromycin GI side effects are common ➢ Macrolide allergic: doxycycline, quinolones

CEPHALOSPORIN ➢ 1 generation: Gram +; Beta-lactam; Cephalexin, Cefadroxil Group A Strep, S. aureus – not MRSA – Keflex (pregnancy UTI, cellulitis, impetigo) ➢ 2nd generation: Gram +/- Broad spectrum – Ceftin, Cefzil – otitis media, rhinosinusitis, CAP, chronic bronchitis ➢ 3rd generation: Gram – with weak Gram +; Betalactam; Cefixime ➢ Extended 3rd generation: Gram +/-; Beta-lactam; Rocephin, Cefdinir – gonorrhea, PID, pyelonephritis, otitis media ➢ Cross reactivity between PCN and cephalosporin usually occurs with 1st generation st

PENICILLIN ➢ Diarrhea, C. Diff, Vaginitis, StevensJohnson syndrome ➢ Avoid amoxicillin for patients with mono (generalized rash) ➢ Dicloxacillin – mastitis & impetigo ➢ Anaphylaxis and angioedema are type 1 IgE ➢ PCN allergic: macrolides

AUGMENTIN ➢ Gram +/-, beta-lactamase. NO MRSA ➢ High-dose 3-4g/day amoxicillin needed for drug-resistant Strep pneumoniae (DRSP) ➢ Clavulanate as beta-lactamase inhibitor so amoxicillin can work on H. influenzae, M. catarrhalis

FLUOROQUINOLONES ➢ Cipro: Gram -; atypical pathogens ➢ Levaquin: Gram +/-; Atypical, DRSP ➢ Achilles Tendon rupture (esp. with steroid use ➢ Contraindicated – less than 18, pregnancy, breast feeding, myasthenia gravis ➢ QT prolongation, hypoglycemia

ANTIBIOTIC THERAPY/PHARMACOLOGY

SULFONAMIDE ➢ Gram -; MRSA; NO STREP, NO E COLI ➢ Contraindications o G6PD anemia causes hemolysis o Newborns and infants < 2 months ➢ HIV patients are high risk for Stevens-Johnson

MEDICATIONS THAT REQUIRE EYE EXAM ➢ Digoxin (yellow to green, blurred vision, halos if blood level too high) ➢ Ethambutol and linezolid (optic neuropathy) ➢ Corticosteroids (cataracts, glaucoma, optic neuritis) ➢ Fluoroquinolones (retinal detachment) ➢ Viagra, Cialis, Levitra (cataracts, blurred vision, ischemic optic neuropathy, others) ➢ Accutane (cataracts, decreased night vision) ➢ Topamax (acute angle-closure glaucoma, increased intracranial pressure, mydriasis) ➢ Plaquenil (neuropathy and permanent loss of vision)

SOUTHEAST ASIAN CULTURE ➢ Vietnamese, Hmong, Filipinos ➢ Pt may have difficulty verbalizing questions about treatment ➢ May consult family about major health decisions ➢ Will not tell provider if not compliant ➢ Would never verbalize disagreement in loud voice – have high regard for physicians ➢ Imbalance of hot and cold (yin/yang) ➢ Male is head of house ➢ Alpha thalassemia is common in Asians, Filipino ➢ View surgery as last resort ➢ Infants and small children may wear amulet

RANDOM HERB FACTS BETA-LACTAMS ➢ Penicillin – Penicillin, Amoxicillin, dicloxacillin, ampicillin and others ➢ Cephalosporin – ceph- or cef- prefix ➢ Carbapenem – imipenem usually given with cilastatin ➢ Monobactam – aztreonam ➢ High rate of allergic reactions

NITROFURANTOIN ➢ Urinary pathogens

➢ Echinacea – immunological effects ➢ Black cohosh, roasted soy beans – acts similar to estrogen for some people ➢ Kava Kava - anxiety ➢ St John’s wort – depression o interacts with oral contraceptives, cyclosporine and select antiretrovirals ➢ Saw Palmetto – BPH ➢ Fish oil and ginseng can cause bleeding ➢ Milk thistle – lower cholesterol, liver problems and diabetes

VITAMIN D DEFICIENCY

METRONIDAZOLE (FLAGYL)

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➢ Anaerobes ➢

FOOD FACTS ➢ Tetracycline and dairy interact ➢ Avoid MAOI and high tyramine containing foods (fermented foods) ➢ Eat salmon and omega-3 for heart disease; plant sterols and stanols reduce cholesterol ➢ Collard greens are high in vitamin K ➢ Magnesium - decreases BP and dilates blood vessels (nuts, beans, wheat, laxatives) ➢ Potassium – decreases BP – most fruits, leafy greens and nuts ➢ Non-dairy calcium includes: tofu, spinach and sardines ➢ Celiac Disease - Avoid gluten, wheat, rye, barley, oats. Gluten free foods: corn, rice, potato, quinoa, tapioca, soybeans

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Vitamin D inhibits abnormal cellular growth; encourages reabsorption and metabolism of calcium and phosphorus; reduces inflammation Skin exposure to sun produces greatest values Someone taking phenytoin needs 2-5x vitamin D Symptoms of vitamin d deficiency o Rickets, osteomalacia, antigravity muscle weakness 25-hydroxyvitamin D is lab measurement A child must drink 32 oz of milk daily to receive recommended 400 IU (infants) of daily vitamin D 600 IU for those age 1-70 including pregnant; 800 IU > 70 Darker skin tones synthesize less vitamin D Sunscreen increase risk of vitamin d deficiency Vitamin d deficiency is common in hepatic, renal and after gastric bypass.

Vitamin D3 is preferred form o 50,000 IU per week x 8 weeks o 1000-2000 daily

HEENT - EYES

CATARACTS EYE

EYE EXAM 1.

➢ Macula – responsible for central vision ➢ Optic Disc – shaped like saucer with indentation where cup goes (balance between intraocular and intracranial pressure) – should be sharp with cup to disc ratio < 0.5 ➢ Veins pulsate and are prominent ➢ Papilledema – optic disc swollen with blurred edges due to ↑ ICP; absent vein pulsations

2.

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➢ Angle closure glaucoma -deeply cupped disc –b/c too much intraocular pressure (cup ratio > 0.5) ➢ Hypertensive Retinopathy o Copper and silver wire arterioles (hard) o AV nicking – artery crosses over vein (atherosclerosis in eye) o Flame hemorrhages

Visual Acuity - with any eye complaint o OU (both) OD (right) OS (left) o Two-line difference between each eye o Can miss up to 2 letters on each line o 20/200 is considered legally blind o By age 6 child can see 20/20 Slit-lamp or binocular loupe - evaluation of anterior eye, including cornea, conjunctiva, sclera and iris o Penlight and do 180 Fluorescein staining Lid Eversion Near vision – ask patient to read small print Triad of ophthalmologic emergency o Red eye, painful eye, new-onset vision change Presbyopia – gradual, age-related loss of eyes’ ability to accommodate stiffening of the lens; unable focus actively on nearby objects; starts around age 40 Amsler grid test – early detection of macular degeneration Tonometry – measures IOP, glaucoma screening test If a protruding object is found – it should not be removed

➢ Diabetic Retinopathy o Microaneurysms o Cotton wool spools (nerve reels dying) o Flame hemorrhages

➢ Chronic steroids, trauma, aging, sunlight, tobacco ➢ Opacity of lens of eye which can be central or on the sides ➢ Difficulty with glare (with headlights when driving at night or sunlight), halos around lights, and blurred vision ➢ Absent red reflex

➢ Retinoblastoma – leukocoria – white reflex

TERMINOLOGY ➢ Palpebral conjunctiva – mucosal lining inside eyelids ➢ Bulbar conjunctiva – mucosal lining covering eyes ➢ Hyperopia – farsighted – distance vision intact, but near vision is blurry ➢ Myopia – nearsighted – near vision is intact, but distance vision is blurry ➢ Xanthelasmas – yellow plaque on the inner canthus – 50% of people have elevated lipids ➢ Uveitis – occasionally dull painful red eye with vision changes, pupil is constricted, nonreactive and irregularly shaped. Tx with pupil dilation, corticosteroids, evaluate underlying cause (autoimmune)

HEENT

CHEILOSIS

LYMPH NODES ➢ ➢

Cancerous nodes are non-tender Tender nodes indicate infection

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MOUTH ➢ Gums may be red and swollen due to gingivitis or taking Dilantin ➢ Salivary glands – parotid, submandibular and sublingual

Painful skin fissures and maceration at corner of mouth o Over salivation, poorly fitting dentures, nutritional deficiencies, lupus, autoimmune disease, irritant dermatitis, squamous cell carcinoma o Remove underlying cause o If yeast – treat with azole ointment BID o If staph – treat with mupirocin ointment BID o When infection clear, use barrier cream at night ▪ Zinc ▪ Petroleum jelly

ORAL CANCER ➢ ➢ ➢ ➢ ➢

➢ Sialadenitis – swelling to side of face (mumps) ➢ Sialolithiasis – calculi or stone – painful lump under tongue - ↑ fluids, moist heat, NSAIDs, antibiotics if infected, surgery to remove stone ➢ Torus palatinus – painless bony protuberance midline on hard palate

Ulcerated lesion with indurated margins Relatively fixed submandibular nodes Squamous cell cancer is most common form Risk factors include male gender, advanced age, tobacco and alcohol abuse, HPV type 16 Screening is recommended at every dental visit

KOPLIK SPOTS ➢

Small-sized red papules white centers inside cheeks

RED EYE COMPLAINTS ➢ Send to ophthalmology o Change in vision o FB sensation with inability to keep eye open o Photophobic ➢ Keep FB sensation, scratchy, gritty o Pink eye

DACROCYSTITIS ➢ Infection of lacrimal sac/tear duct usually caused by blockage ➢ Common in infants, adults > 40 ➢ Thick eye discharge, pain, redness, swelling, warmth of lower eyelid, watery eye, excess tears ➢ Treatment: lacrimal sac massage (downward towards mouth) 2-3 times daily, antibiotics 7-10 days

NOSE ➢ Only inferior nasal turbinates are seen ➢ Pale, boggy, bluish nasal turbinates are seen in allergic rhinitis ➢ Sinus cavities – frontal appear by age 5 and sphenoid by age 12 ➢ Rhinitis Medicamentosa - Prolonged use (> 3 days) of topical nasal constrictor/decongestants

HEENT

EAR BACTERIA OF THE EAR

Location Cause

Weber Result – tuning fork on forehead

Rinne Result – mastoid then front of ear Treatment

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Conductive Outer or middle ear Sound is being blocked (earwax, foreign objective, damaged eardrum, serous otitis media, bone abnormality – cholesteatoma) Sound lateralizes to affected ear (buzzing sound heard louder in affected ear) – otitis media, ceruminosis, perforation of TM Negative (BC > AC)

Sensorineural Inner ear Inner ear or nerve becomes damaged (advanced age, ototoxic medications, immune disorders, trauma) Sound lateralizes to unaffected ear (buzzing sound not at all in affected ear- numbness) – Presbycusis Meniere’s disease Normal (AC > BC) or positive **can hear longer in front of ear than on mastoid bone Hearing aids or cochlear implants possible options with expert communication

Often self-resolves post cerumen impaction removal, post URI or AOM resolution. Rarely, further pharmacologic or surgical intervention is needed **Temporary **Permanent Acoustic nerve or CN VIII Vestibulocochlear – Auditory Presbycusis – age related hearing loss; difficulty appreciating content in noisy environment

➢ S. pneumoniae – usually causes most significant symptoms and is least likely to resolve without antibiotics o Resistance to low dose amoxicillin, certain cephalosporins and macrolides o Mechanism of resistance is alteration of intracellular protein-binding sites ▪ Use high dose amoxicillin and select cephalosporins o Risk factor is recent antibiotic use ➢ H. influenza and M. catarrhalis o Gram negative capable of producing beta lactam ring o High rate of spontaneous resolution o H. influenza is most common found in mucoid and serous middle ear infection ➢ Treatment o No recent antibiotics ▪ Amoxicillin high dose TID ▪ Augmentin BID ▪ Cefdinir o Recent antibiotic use ▪ Augmentin BID ▪ Levofloxacin or Moxifloxacin ➢ Otitis Media with Effusion o Symptomatic treatment o Can last 8 weeks

➢ Bones – Malleus, incus and stapes ➢ Tympanogram – test for presence of fluid inside middle ear (straight line vs peaked shape) ➢ Pinna injuries – refer to plastics ➢ Tragus – small cartilage flap of tissue in front of ear ➢ Ceruminosis – carbamide peroxide

HEENT EMERGENCIES

Name

Herpes Keratitis

Cause

Herpes simplex (Herpes Simplex Keratitis) or herpes varicella zoster (Herpes Zoster Ophthalmicus)

Signs/Symptoms

Acute onset of severe eye pain, photophobia, tearing and blurred vision in one eye Herpes Zoster Ophthalmicus – acute crusty rashes that follow ophthalmic branch (CN V) of trigeminal nerve (one side forehead, eyelids and tip of nose) can result in blindness

Elderly patient with acute onset of severe eye pain with redness and vision changes.

Accompanied by headache, N/V, halos around lights and decreased vision.

Acute AngleClosure Glaucoma

Diagnostics

Treatments

Concerns

Refer to ED

Infection permanently damages corneal epithelium – corneal blindness

Refer to ED

Ophthalmological emergency 2nd leading cause of blindness Risk factors: Asian ethnicity, female gender, far-sightedness

Fluorescein dye Fern like lines in corneal surface (corneal abrasions are round or irregularly shaped)

Mid-dilated pupil oval shaped. Cornea appears cloudy. Funduscopic exam reveals mid-dilated cupping of optic nerve

Angle (door) closing in eye – pain

Young adult female with new or intermittent loss of vision of one eye alone or accompanied by nystagmus or other abnormal eye movements. (aphasia, paresthesia, abnormal gait, spasticity).

Daily fatigue upon awakening that worsens as day goes on. Heat exacerbates symptoms. Has recurrent episodes.

Acute onset of erythematous swollen eyelid with proptosis (bulging of eyeball) and eye pain on affected side. Unable to perform ROM of eyes.

Abnormal EOM with pain on eye movement. Hx of recent rhinosinusitis or URI

Optic Neuritis

Multiple Sclerosis

Orbital Cellulitis

Acute bacterial infection of orbital contents

Retinal Detachment

Risk factors: myopia, cataract surgery, diabetic retinopathy, hx of retinal detachment, older age, trauma

Sudden onset of shower of floaters associated with looking through a curtain sensation with sudden flashes of light (photopsia). Associated symptoms include unilateral photophobia, wavy distortion of an object.

Refer to ED

Keratinizing squamous epithelium

Cauliflower like growth accompanied by foulsmelling ear discharge. Hearing loss on affected ear. No tympanic membrane or ossicles are visible because of destruction by tumor. Hx of chronic otitis media infection. Mass is not cancerous but can erode into bones of face and damage facial nerve (CN VII)

Refer to otolaryngologist.

Treated with antibiotics and surgical debridement

Cholesteatoma

Refer to neurologist

Refer to ED

More common in young children

HEENT EMERGENCIES CONTINUED

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Battle Sign

Trauma

Raccoon eyes (periorbital ecchymosis) and bruising behind the ear (mastoid area) that appears 2-3 days after trauma.

Search for clear golden serous discharge from ear or nose.

Rule out basilar or temporal bone skull fracture.

Basilar skull fractures can cause intracranial hemorrhage. Refer to ED

Clear Golden Fluid Discharge from Nose/Ear

Basilar skull fracture

Clear golden fluid discharge from nose/ear

Test fluid with urine dipstick – positive for glucose (plain mucous or mucopurulent drainage is negative)

Refer to ED

Peritonsillar Abscess

Severe sore throat with difficulty swallowing, odynophagia (pain on swallowing) and a “hot potato voice” Unilateral swelling of peritonsillar area and soft palate. Affected area is markedly swollen and appears as a bulging red mass with uvula displaced away from mass. Accompanied by malaise, fever and chills.

Refer to ED

Diphtheria

Sore throat, fever and markedly swollen neck (bull neck) Low grade fever, hoarseness and dysphagia. Posterior pharynx, tonsils, uvula and soft palate are coated with gray to yellow colored pseudomembrane that is hard to displace. Very contagious. Contact prophylaxis required.

Refer to ED

Epiglottitis

Sore throat, fever, muffled voice, drooling, stridor, hoarseness “hot potato”, “thumb sign”

Refer to ED

Concerns

Hib vaccine eradicated in kids

HEENT

Name

Cause

Signs/Symptoms

Acute onset severe eye pain with tearing. Reports feeling of foreign body sensation on surface of eye.

Always ask about contacts

Corneal Abrasion

Diagnostics

Treatments

Concerns

Fluorescein dye. Linear or round

Flush eye with sterile normal saline. Evert eyelid to look for foreign body. Topical antibiotic trimethoprim-polymyxin B (Polytrim), Ciprofloxacin (Ciloxan), Ofloxacin (Ocuflox) to affected eye 3-5 days.

Do not patch eye.

Contact Lens-Related Keratitis – acute onset red eye, blurred vision, watery eyes, photophobia, foreign body sensation

Can cause cellulitis of eyelid

Hordeolum (Stye)

Abscess of hair follicle and sebaceous gland in upper or lower lid.

Internal – inflammation of meibomian gland

Acute onset swollen, red and warm abscess on the upper or lower eyelid. May spontaneously rupture and drain purulent exudate.

Hot compresses x 5-10 minutes BID – TID until drained May need dicloxacillin or erythromycin PO QID

Chalazion

Chronic inflammation of meibomian gland

Gradual onset of small superficial nodule on upper eyelid that feels like a bead and is discrete and moveable. Painless. Can slowly enlarge over time. If large enough, can press on cornea and cause blurred vision.

I&D, surgical removal or intrachalazion corticosteroid injections.

Pinguecula

Chronic sun exposure

Raised yellow to white small growth in the bulbar conjunctiva (skin covering eyeball) next to the cornea

Pterygium

Chronic sun exposure

Yellow triangle wedge-shaped thickening of conjunctiva that extends across the cornea on the nasal side. Surfer’s eye. Can be red or inflamed at times. May complain of foreign body sensation on the eye. Non-cancerous

Subconjunctival hemorrhage

Coughing, sneezing, heavy lifting, vomiting, local trauma, spontaneously

Blood trapped underneath the conjunctiva and sclera secondary to broken arterioles.

Watchful waiting and reassurance of patient

Primary OpenAngle glaucoma

Elevated intraocular pressure Risk factors: African ancestry, Type 2 DM, advanced age, family hx of POAG

Gradual onset of increased IOP greater than 22 due to blockage of drainage of aqueous humor inside eye; most common in elderly; usually asymptomatic during early stages. Gradual change in peripheral vision then central vision (tunnel vision). May complain of missing portions of words when reading. If cupping of optic disc– IOP is too high

Refer to ophthalmologist.

Check IOP with tonometer. Normal 8 to 21 (>30 is very high) Betimol 0.5% - ↓ aqueous production (beta/alpha blockers) Latanoprost – topical prostaglandin SE of med: bronchospasm, fatigue, depression, heart failure, bradycardia Contraindicated asthma, COPD, heart failure

Most common glaucoma.

Blindness due to ischemic damage to retina.

2nd leading cause of blindness Risk factors: postural hypotension, hx of fungal conjunctivitis, white race

Macular degeneration

gradual damage to pigment of macula (area of central vision) results in severe visual loss to blindness

Asymptomatic in the early stages. Complains of gradual or sudden and painless loss of central vision in one or both eyes. Straight lines become distorted or curved (scotoma). More common in smokers

Refer to ophthalmologist. Pt is given Amsler grid to check vision loss daily to weekly Atrophic (dry form) or exudative (wet form) – wet is responsible for 80%

Most common cause of vision loss. Leading cause of blindness in elderly Risk factors: age, smoking

Sjogren’s Syndrome

Chronic autoimmune disorder

Decreased function of lacrimal and salivary glands. Persistent daily dry eyes and mouth (xerostomia) for > 3 months. Eyes have sandy or gritty sensation. Uses OTC artificial tears TID

OTC tear substitute TID Refer to ophthalmology, dentist and rheumatology

If inflamed, refer to ophthalmologist for RX of weak steroid eye drops only during exacerbations. Use artificial tears as needed for irritation. Good quality sunglasses 100% UVA and UVB. Remove surgically if encroaches on cornea and affects vision

HEENT

Name

Cause

Signs/Symptoms

Blepharitis

Inflammation of eyelids associated with seborrheic dermatitis and rosacea

Allergic conjunctivitis

IgE mediated response

Suppurative conjunctivitis

Pseudomonas aeruginosa

Allergic rhinitis

IgE mediated disease due to genetic and environmental interactions “Asthma in the head”

Epistaxis

Idiopathic, digitorum, ASA, NSAIDs, cocaine, HTN, anticoagulants place pt. at higher risk

Strep throat

Streptococcus pyogenes or Group A beta Strep (incubation is 3-5 days) M. ↑ is often common in teenagers and adults with same symptoms, but dry cough (incubation 3 weeks)

Acute Otitis Media

Strep pneumoniae H. influenzae M. catarrhalis

Acute viral rhinosinusitis (AVRS) Acute bacterial rhinosinusitis (ABRS)

Secondary bacterial infection usually following viral URI Strep pneumoniae H. influenzae (common in smokers) M. catarrhalis

Treatments

Concerns

Itching or irritation in the eyelids (upper, lower or both), gritty sensation, eye redness and crusting.

Johnsons baby shampoo with warm water.

Gently scrub eyelid margins until resolves.

Consider erythromycin eye drops to eyelids 2-3 times day. Warm compresses to lids 2-4 times a day to soften debris

Seborrheic dermatitis – inflammatory Malassezia, respond to antifungals, worse in winter

Itchy, watery, red eyes Rope-like yellow discharge (eosinophils), chemosis, eyelid edema, allergic shiners

Cool compresses, artificial tears, Ocular antihistamine, cromolyn, oral antihistamines

Red, irritated eye with eyelids that were “stuck together” – injected palpebral and bulbar conjunctiva

Polymyxin B plus trimethoprim, levofloxacin, azithromycin

Itchy eyes, nose, or throat. Nasal congestion, rhinorrhea, postnasal drip, sneezing. Cough worsens when supine.

Pollens – most common seasonal allergen; dust mites – most common perennial allergen; mold spores – common indoor allergen Acute onset nasal bleeding. Possible vomiting of blood. Anterior nose bleeds (Kiesselbach’s plexus) are milder and more common than posterior nose bleeds (Sphenopalatine or carotid artery) Abrupt onset sore throat, fever, headache, tender, localized anterior cervical lymphadenopathy. Dark pink to bright red pharynx. Tonsillar exudate yellow to green in color. Petechiae on hard palate.

Scarlet fever or scarlatina (sandpaper-like rash) with strawberry tongue. Rash usually erupts on day 2 and often peels a few days later.

Most adults do not get strep, but *** immunocompromised or those who have high exposure due to job or lifestyle Otalgia, popping noises, muffled hearing, recent cold or allergies. Moderate or severe bulging of TM or new onset otorrhea not related to otitis externa (OE); erythema, mild bulging of TM and recent onset of ear pain

Unilateral facial pain or upper molar pain for 10 days or longer with purulent nasal or post nasal drip. Head congestion, fever, sore throat, cough.

Self-treatment with OTC provide no relief

Diagnostics

Nose has blue-tinged or pale boggy nasal turbinates.

Mucus clear. Posterior pharynx thick mucus with possibly cobblestoning.

Undereye circles.

Strep screen CENTOR Score • Tonsillar exudate • Anterior cervical adenopathy • Hx of fever • Absence of cough Age 3-14 +1; 15-44 0; 45+ -1 Score > 2 screen for strep Non-severe: mild otalgia < 48hrs. or fever <102.2 in past 24 hours Severe: moderate/severe otalgia, otalgia > 48 hrs. or fever > 102.2 HPI- bacterial Persistent and not improving (>10days); fever Severe > 3-4 days Worsening or double sickening transillumination

First line: Remove or avoid allergen. · Intranasal corticosteroids (down regulates inflammatory response) takes 2-7 days · Add Astelin. · Cromolyn sodium TID – mast cell stabilizer · Use decongestants – nasal congestion · Oral antihistamines (block H1) – itch Direct pressure. Nasal decongestants (Afrin oxymetazoline) – silver nitrate (ouch) Apply triple antibiotic ointment or petroleum jelly in front of nose with cotton swabs for a few days.

PCN V 500 BID-TID x 10 days Amoxicillin 500 BID x 10 days PCN allergic: Zpak x 5 days Ibuprofen/Tylenol Salt water gargles, throat lozenges, drink fluids If H. influenza - Augmentin or cephalosporin If M. pneumoniae – macrolide or fluoroquinolone Non-severe – watchful waiting; Treat with amoxicillin 80-90mg, if recent abx then Cefdinir followed by Augmentin. (< 2 yrs. 10 days, 2-6= 7 days, >6 = 5-7 days) if pt. has mono do not give Amoxicillin – will have morbilliform rash; tympanic membrane rupture with hearing loss – Refer to ENT Symptomatic tx: Saline nasal irrigation, intranasal corticosteroids, decongestants, mucolytics First line: Augmentin 875/125 or 1000/62.5 or 2000/125 BID 5-7 days Allergy to PCN/Cephalosporin: Doxycycline 100mg BID or Levofloxacin 500mg daily or Moxifloxacin 400mg daily; Cefdinir, Ceftin, Vantin BID 5-7 days

Medications normally sting the eye temporarily

Adenovirus is most common cause of viral conjunctivitis Avoid 1st generation antihistamines due to sedation (chlorpheniramine, diphenhydramine, carbinoxamine, brompheniramine) Posterior nasal bleeds can lead to severe hemorrhage Viral if cough, rhinorrhea, coryza (watery eyes).

If not treated can cause rheumatic fever – rash is increased risk Post-strep glomerulonephritis – proteinuria, hematuria, dk urine, RBC cast, HTN edema Bullous myringitis – blisters on red and bulging TM. Conductive hearing loss. Tx same as AOM. Expect sensation of ear fullness up to 8 weeks Watchful waiting: 10 days No macrolides Treatment 5-7 days = efficacy, fewer complications, better compliance

HEENT

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Otitis Externa

Pseudomonas aeruginosa S. aureus Proteus spp.

Enterobacteriaceae

External ear pain, swelling, discharge, pruritus and hearing loss. Hx of recent activities that involve swimming or getting the ear wet. Ear pain with manipulation of external ear or tragus.

Purulent green discharge. Erythematous ear canal

Physical exam, if malignant consider CT, radionucleotide bone scan, gallium scan, MRI

Polymyxin B-neomycin-hydrocortisone suspension (Corticosporin Otic) 4 gtts QID x 7 days; Ofloxacin otic or Ciprofloxacin otic ear drops BID x 7 days. Keep water out of ear. (No steroids if eardrum ruptured)

EBV (incubation is 30-50 days)

Malaise and fatigue, Fever, pharyngitis, lymphadenopathy. Hx of sore throat, enlarged posterior cervical nodes and fatigue for several weeks. May have abdominal pain. Virus is shed through saliva 50% have splenomegaly (normal spleen is 1 x 3 x 5, weighs 7 oz and lies between 9 and 11 ribs)

CBC: atypical lymphocytes and lymphocytosis; LFT: abnormal for several weeks; Heterophile antibody test: Monospot +; Large cervical nodes; Erythematous pharynx with inflamed, sometimes white exudate; Hepatomegaly and splenomegaly; red maculopapular rash

Limit physical activity for 4 weeks.

Abd US is splenomegaly/hepatomegaly.

Repeat US in 4 to 6 weeks. Avoid amoxicillin.

Avoid close contact, kissing, sharing utensils.

If airway obstruction, hospitalize with high dose steroids

Mononucleosis

Aphthous stomatitis

unknown

Painful shallow ulcers on soft tissue of mouth that usually heal within 7-10 days

Geographic tongue

Benign physiological variant

Multiple fissures and irregular smooth areas looking like a topographic map. May have soreness after eating or drinking acidic or hot foods

Leukoplakia

Poor fitting dentures, chewing tobacco, alcohol abuse

Slow growing white plaque with firm to hard surface, slightly raised on tongue, floor of mouth or inside cheek

Precancerous lesion

refer

Present with episodes of vertigo with a sensation that the room is whirling about – preceded by decreased hearing, tinnitus and feelings of increased pressure. Characterized by repeat attacks that last minutes to hours and can be related to food and drinks, mental and physical stress and variations in menstrual cycle

Largely diagnosis of exclusion. Horizontal nystagmus usually towards the affected ear with rapid correction to midline. Weber lateralizes to unaffected ear.

Rinne’s AC>BC; performing pneumatic otoscopy in affected ear can elicit symptoms. Romberg + Fukuda marching step test is positive with drift towards affected ear. Dix-Hall Pike is occasionally also positive indicating BPPV

Antihistamines such as meclizine, antiemetics or benzodiazepines can minimize symptoms, thiazide diuretics can decrease pressure load in ear and prevent but not treat attacks. Corticosteroids have also been demonstrated to be helpful Prevention: avoid ototoxic drugs, protecting ears from loud noise and limiting sodium intake

Increased pressure within endolymphatic system

Preventative: Domeboro (boric) or alcohol and vinegar

Peak ages 15-24 3F’s and an L Fever, Fatigue, Pharyngitis and Lymphadenopathy

Magic mouthwash – liquid diphenhydramine, viscous lidocaine and glucocorticosteroid

Aphthous ulcer – canker sore

Meniere’s disease

Concerns

Risk factors include: use of ototoxic drugs such as aminoglycosides, longterm high dose salicylate use, certain cancer drugs and long-time exposure to loud noise. Can also have Meniere’s symptoms with certain situations but not the disease

SKIN/INTEGUMENTARY SYSTEM

DERMATOLOGY ASSESSMENT TIP ➢ ➢ ➢ ➢ ➢

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Assess the entire patient, not simply the skin problem.

Consider whether there is transmission/contagion risk.

Where did it start? (face, torso, extremities, genitals) How long have you had it?

Does it itch?

Is the patient otherwise well? o Disease limited to skin such as rosacea, keratosis pilaris, seborrheic dermatitis.

Is the patient miserable, but not systemically ill? o Itch, burning, pain – scabies or shingles Is the patient systemically ill with constitutional symptoms (fever, fatigue, loss of appetite, unintended weight loss, malaise)? o Varicella, transepidermal necrosis, Lyme disease, systemic lupus erythematosus Primary lesions only? Primary and Secondary? o Where is oldest lesion - when did it occur? o Where is newest lesion – when did it occur? o Primary – result from disease process, has not been altered by outside manipulation or tx ▪ Ex: vesicle – fluid filled < 1 cm (varicella, shingles, herpes) o Secondary – lesion altered by tx or progression of disease ▪ Ex: Crust – raised lesion caused by dried serum and blood remnants, develops when vesicle ruptures

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SMALLPOX ➢ ➢ ➢ ➢ ➢

“Eliminated” 1977 Infection targets respiratory and oropharyngeal surfaces. Incubation period of 2 weeks.

Flu-like signs and symptoms with large nodules in center of face, arms and legs. Symptomatic treatment Mortality rate 20-50% If vaccine given within 3-4 days postexposure, can lessen severity of illness

SKIN CANCER ASSESSMENT

SKIN LESIONS

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Annular – in a ring (Bull’s eye lesion – Lyme disease) – central clearing Bulla – blisters > 1cm w/fluid (burn) Clustered - lesion occurring in a group without pattern (herpes) Confluent or Coalescent- multiple lesions blending together (psoriasis vulgaris) Cyst – raised, encapsulated fluid filled lesion (intradermal lesion) Lichenification – skin thickening usually found over pruritic or friction areas Linear - lesion distribution in streaks (poison ivy) Macule – flat non-palpable are of discoloration <1cm (freckle) Maculopapular – both color and small papules or raised skin lesions ranging from erythematous to bright pink Nodule – solid lesion > 0.5 – 2 cm (> 2 cm tumor) Papule – solid elevation <0.5 cm (mole) o Smooth papule dome shaped with central umbilication with white plug (molluscum contagiosum) Patch – flat, nonpalpable area of skin discoloration larger than macule (vitiligo) Petechiae – < 1cm (thrombocytopenia) Plaque – elevated, variable shape >1cm (psoriasis) Purpura – flat, red-purple discoloration that does not blanch with pressure Pustule – vesicle like lesion with purulent content (impetigo) Reticular – netlike cluster Scale – raised superficial lesions that flake with ease (dandruff) Scattered – generalized over body without specific pattern (viral exanthem – rubella/roseola) Vesicle – clear fluid (herpes) Wheal – circumscribed area of skin edema (urticaria)

A – Asymmetry B – Border irregularity C – Color (brown, black, red, white, blue) D – Diameter >6mm (pencil eraser) E – Evolving/Elevated (most are new) ➢ ➢ ➢

➢

> 2 features ABCDE 100% sensitive, 98% specific Melanoma: dark colored moles with uneven textures – may be pruritic Acral lentiginous melanoma: most common in AA/Asian. Nailbeds, palms/feet Subungual hematoma: direct trauma to nailbed causing bleeding between bed and finger – trephination – draining the nailbed

PRESSURE ULCER ➢ ➢ ➢

➢

Stage I: nonblanchable erythema on intact skin Stage 2: presence of epidermal or dermal skin loss; can appear as intact blister Stage 3: full-thickness skin loss with exposure of some amount of fat, ulcer has crater-like appearance Stage 4: full-thickness skin and tissue loss; would exposes muscle, bone and tendons

SKIN/INTEGUMENTARY SYSTEM

• •

• • • • • • • •

Potency class 7 (low) to 1 (high) Non-folded trunk and extremities o Triamcinolone 0.1% o Face and body folds – Desonide or hydrocortisone o Palms/soles – fluocinolone or clobetasol Lotions < creams < gels < ointments Creams absorb well and lack greasy texture (sting if open wound) Ointments contain emollient (pounding form of absorption) Lotions water based and spread easily (most gentle) Face greatest rate of absorption, then axilla and genitals 2gm hands, head, face, anogenital 3gm arm, anterior or posterior trunk 30-60gm of topical cream for entire body

BURN ➢ ➢

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st

1 degree – reddened easily blanched with gentle pressure 2nd degree (partial thickness) – red, moist with peeling borders and scattered bulla (Silvadene or polysporin) 3rd degree (full thickness) – thickened, hypopigmented tissue Refer o Face, hands, feet, genitals, major joints o Electrical burns, lightning burns o Partial thickness > 10% BSA o 3rd degree any age o Circumferential P. aeruginosa, E. coli, K. pneumoniae

SKIN/INTEGUMENTARY SYSTEM

WOUNDS

SKIN FINDINGS o o o

o o o o o o o o o o o o o

Fifth disease – maculopapular rash in lace-like pattern Varicella, zoster, herpes simplex – maculopapular rashes with papules, vesicles and crust (vesicular rash on erythematous base) Pityriasis rosea – maculopapular rashes that are oval shaped with a herald patch (Christmas tree) Seborrheic Keratosis – soft, wart-like growth on trunk ranging from light brown-black; pasted on appearance Xanthelasmas – raised, yellowish plaques under brow or lids. Sign of high lipids Melasma – pregnancy mask. On upper cheeks and forehead Vitiligo – hypopigmented patches of skin w/ irregular shapes Cherry angioma – benign small papules bright cherry red in color, always blanch with pressure Lipoma – fatty cystic tumors of subcutaneous layer on neck, trunk, legs, arms Nevi (moles) – round macules/papules varying in color and size – benign Xerosis – inherited extremely dry skin of mouth and eye Acanthosis Nigrans – velvety thickening of skin behind neck/axilla; associated with DM, metabolic syndrome, obesity, and GI cancer tract Acrochordon – skin tags. Painless pedunculated outgrowths of skin are the same color.

Candida – bright-red with satellite lesions Intertrigo – bright-red diffused rash due to bacterial infection Acral – on extremities

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Factors that impair wound healing o Older age, poor nutrition, impaired immune system, impaired mobility, stress, diabetes, medications (impair clot formation and steroids), pressure loading, smoking, secondary bacterial infection Primary healing – wound closed within 24 hours by suturing, tissue glue or butterfly strips Secondary healing – would is left open and heals from bottom up Tertiary intervention – wounds with heavy contamination or poor vascularity (crush injuries) are best left open to heal by secondary intention.

Referral – infected wounds, closed-fist injury, facial wounds with risk of cosmetic damage, foreign body or embedded object, injury to joint capsule, electrical injuries, paint-gun or high-pressure wounds, chemical wounds, child abuse Do not suture wounds > 24 hours - ↑ infection risk > 12 hrs.

Tdap if last tetanus was > 5 yrs.

Suture removal o Face: 5-7 days o Scalp: 7-10 days o Upper extremities: 7-10 days o Lower extremities: 10-14 days

RANDOM FACTS o o

o

o

Bed bugs: do not infect the patient Squamous cell carcinoma: sun exposed areas, lower lip common in smokers • Presents as papule, plaque, nodules, smooth, hyperkeratotic or ulcerative lesion • May bleed easily • Definitive diagnosis is biopsy or excision of specimen – moles procedure?

▪ N - nodular ▪ O - opaque ▪ S – sun-exposed ▪ U - ulcerating ▪ N – nondistinctive borders Irritant contact dermatitis – contaminated water, soaps and detergents, fiberglass, particulate dust, food products, cleaning agents, lubricants, oils, coolants, solvents, plastics, resins, petroleum products Allergic contact dermatitis – poison ivy, rubber, nickel, fragrances

LICHEN PLANUS ➢ ➢ ➢

Small, flat red to purple bums with white scales Itch – common on wrist, forearms, ankles Common causes include Hepatitis C – self-limiting

ODE TO MRSA ➢

ABCD o o o o

MRSA Bactrim Clindamycin Doxycycline

SKIN/INTEGUMENTARY SYSTEM Name

Rocky Mountain Spotted Fever

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Dog/Wood Tick bite Rickettsia rickettsii

high fever, chills, severe headache, n/v, photophobia, myalgia, conjunctival injection, arthralgia; 2-5 days after onset - rash (petechiae) starts on hands/feet to trunk (palmar rash)

Antibody titers to rickettsia Punch biopsy CBC, LFT, CSF

Doxycycline 100mg BID for 7-14 days – can be fatal if not started on treatment within 8 days. Remove tick by grasping closest to skin and apply steady upward pressure.

Can be fatal (3-9%) Highest in southeastern/south central regions of US Most common Apr - Sept

Brown recluse spider bite

Fever, chills, nausea and vomiting. Red, white and blue sign; central blistering with surrounding gray to purple discoloration at bite surrounded by blanched skin surrounded by large areas of redness

Erythema Migrans (Lyme disease)

Borrelia burgdorferi (tick)

Expanded red rash with central clearing (bullseye), feels hot to touch and rough texture; common areas belt line, axilla, popliteal, groin FLU-LIKE symptoms Rash appears 7-14 days after deer tick bite Spontaneously resolves

Meningococcemia

Neisseria Meningitides Gm – diplococci Spread via respiratory

sudden onset of sore throat, cough, fever, headache, stiff neck, photophobia, and changes in LOC abrupt onset of petechial to hemorrhagic rashes

Varicella / Zoster

Herpes-zoster (Chickenpox or Shingles) – spread by direct contact or inhalation

Chickenpox: Fever, pharyngitis, malaise Pruritic vesicular lesions beginning at head expanding to trunk (vesicles and crust) – most common on thorax Shingles: lesions at various stages along dermatome Contagious 1-2 days before rash until crusted

Malignant Melanoma

Basal Cell Carcinoma

Most common skin cancer

Slow-growing; Scaling, dry, round, flesh-colored lesions on skin that do not heal; usually sunexposed areas; sizes range from microscopic to several centimeters

Actinic Keratosis

Erythema Multiforme (Stevens-Johnson syndrome)

A – Asymmetry B – Border irregularity C – Color (brown, black, red, white, blue) D – Diameter >6mm (pencil eraser) E – Evolving/Elevated (most are new) May be pruritic Waxy, pearly domed nodule, usually distinct borders with or without telangiectasia; white, light pink, brown or flesh colored. Papule, nodule with or without central erosion PUT ON (Pearly papule, Ulcerating, Telangiectasia, On the face, scalp, pinnae, Nodules, slow growing

Rare reaction to medications (NSAIDs, Sulfa, antiepileptic), infection (herpes or Mycoplasma pneumoniae) and malignancies

Lesions like “bulls-eye”, erupt suddenly Hives, blisters, petechiae, purpura, hemorrhagic lesions and sloughing of epidermis. Could have prodrome of fever with flulike symptoms 1-3 days before rash appears (palmar rash)

Enzyme immunoassay (EIA) Indirect immunofluorescence assay (IFA)

Ice at time of bite. Local debridement, antibiotic ointment, elevation, loose immobilization. NSAIDs Prevention: look before putting body part into places where spiders hide such as footwear and boxes Early: Doxycycline BID x 14-21d (maybe 28 days) (Alt: Amoxicillin or Ceftin) Avoid doxycycline in children due to teeth staining.

Stage 1: single painless annular lesion Stage 2: AV heart block, Bell’s palsy Stage 3: joint pain 1 yr. after infection

Found in midwestern and southeastern US

NE regions of US Systemic infection with organ shutdown Guillain-Barre Migratory arthritis

Lumbar puncture: CSF Blood/throat cultures CT or MRI of brain

Rocephin 2G IV q12h + Vancomycin IV q12h Hospital isolation and supportive tx Close contact prophylaxis: Rifampin BID x2d and meningococcal vaccine

Death within 48 hours Medical emergency – REFER College students in dorms ↑ risk asplenia, sickle cell, HIV

Viral culture PCR for ZDV Vaccine: >60 Tzanck smear confirms shingles

Varicella: Acyclovir within 24-48 hrs. of eruption (avoid ASA and NSAIDs) Acyclovir or Valacyclovir x 10d for initial outbreak and then x 7 days for flare-ups Post herpetic neuralgia: TCA, anticonvulsant, gabapentin, lidocaine or capsaicin cream to intact skin

Herpes zoster ophthalmicus (corneal blindness) CN V photophobia, eye pain, blurred vision

Needs biopsy by derm.

Refer to Dermatology Acral Lentiginous Melanoma – African American and Asians, located on nail beds, palmar and plantar surfaces

Risk factors, family hx of melanoma, sun exposure, tanning beds, lots of nevus, light skin/eyes

Risk factors: light-colored skin, Australian decent, sunexposed area

Metastatic risk low, significant tissue destruction risk without treatment. Slow growing – common in fair skin types Excisional biopsy

Clinical diagnosis

fluorouracil cream (5FU cream); 5% imiquimod cream, topical diclofenac gel Liquid nitrogen, laser resurfacing or chemical peel Gold standard: refer to derm for biopsy

Pre-cancerous Precursor to squamous cell carcinoma

Toxic Epidermal Necrolysis (TEN) (>30% of skin) allopurinol, anticonvulsants, sulfa, NSAIDs

SKIN/INTEGUMENTARY SYSTEM Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Psoriasis

Inherited; excessive mitotic grown of epithelial cells

Erythematous papules and plaques “fine-silvery scales” found over elbows, scalp, knees, gluteal folds; pitting of fingernails Auspitz sign: Pinpoint areas of bleeding remain in the skin when a plaque is removed.

Chronic Koebner phenomenon – scar formation in places not near typical psoriasis

First Line: Medium potency topical corticosteroid, Second Line: Vitamin D derivatives Topical retinoids (tazarotene), Tar preparations; UVB light and topical tar may induce remissions **BB can exacerbate

Psoriatic arthritis: painful red, warm and swollen joints. Guttate psoriasis: severe form resulting from Gp A strep infection

Tinea Versicolor

Yeast - Pityrosporum orbiculare or Pityrosporum ovale.

KOH slide: hyphae & spores “spaghetti & meatballs”

Topical selenium sulfide Ketoconazole (Nizoral) BID x 2w Oral antifungals

Hypopigmented round macules on chest/shoulders/back; appear after skin is tanned from sun asymptomatic Pruritic rash on hands, flexural folds, and neck; well-demarcated round-to-oval erythematous coin-shaped plaques exacerbated by stress and environment; Starts as small vesicles that rupture leaving red, weeping lesions that become lichenified and itchy

Atopic Dermatitis (Eczema)

Inherited pruritic rash

Acute cellulitis

Strep pyogenes Staph Aureus (MSSA or MRSA)

Infection of dermis and subcutaneous fat with heat, redness and discomfort in the region, poorly demarcated

Cutaneous abscess, furuncle, carbuncle

Staph Aureus (MSSA or MRSA)

Skin infection involving hair follicle and surrounding tissue (heat, redness and discomfort) Carbuncle – multiple abscesses

Erysipelas

S. pyogenes

Sudden onset one hot, indurated, erythema with clear demarcation. Usually on lower legs or cheeks

Bite wounds

Dogs & Cats (P. multicoda) gram negative Humans (Eikenella corrodens)

Hidradenitis Suppurative

Bacterial infection of axillary sebaceous gland Staph aureus

Acute onset painful, large, red nodules and papules under one or both axilla that become abscessed

Staph Aureus Strep pyogenes

Nonbullous – erythematous macule evolves into pustule ruptures leaving honey crusted exudate.

Bullous – clear, yellow fluid ruptures within 1-3 days leaving a rim of red with moist base (scalded appearance) - deep ulcerated=ecthyma Contagious and pruritic: worse in warm weather

Impetigo

Human bite dirtiest of all Cats higher risk of infection than dogs Rabies: skunks, raccoons, foxes, coyotes: Immune globulin and vaccine Quarantine domestic animals for up to 10d

Clinical diagnosis

C&S

Skin lubricants/hydrating baths to alleviate dryness Topical steroids: Mild – hydrocortisone 12.5% Medium – triamcinolone Med/High potency (Halog) x 10d Oral antihistamines for pruritis Non-purulent: Cephalexin 500mg QID, dicloxacillin QID or Clindamycin x 10 day MRSA: Bactrim, Doxycycline or Clindamycin Td booster if >5yrs **Good follow-up; 48 hrs. after initial tx.

I & D and warm soaks Bactrim, Doxycycline or clindamycin MSSA: Dicloxacillin or Cephalexin

Formation of fissures and risk of infection Triad – allergies, eczema, asthma Refer if s/s don’t resolve, cellulitis not responding to tx, spreading quickly, DM, immunocompromised Osteomyelitis, sepsis Bactroban for folliculitis

Non-purulent: Keflex or dicloxacillin Hospitalization for infants, immunocompromised

Wound C&S

Augmentin 875mg x 10d (PCN allergic: doxycycline or Bactrim + Flagyl or clindamycin) Clean, no sutures, tetanus Follow-up 24-48 hours

Watch for closed-fist injury (infection of the joints) 80% cat bites become infected

C & S of drainage

Mild: Chlorhexidine; Clindamycin 1% for 12 weeks; Tetracycline 500 BID; doxycycline or minocycline BID for 7-10 days

Recurrences and scars

C & S of crusts/wounds

Nonbullous - mupirocin ointment 2% x10d (treats select gram + organisms) Cephalexin or dicloxacillin QID x 10d Azithromycin if PCN allergic 250 x 5d or clindamycin x10d

No school until 48-72 hours after treatment initiation

SKIN/INTEGUMENTARY SYSTEM

Name

Herpetic whitlow

Pityriasis Rosea

Cause

Signs/Symptoms

HSV 1 or 2

Painful blistering on side of finger or cuticle Direct contact with cold sore or genital herpes

Unknown may be viral

Oval plaque with central salmon-colored area and dark red peripheral zone on anterior trunk.

Fine scales following skin lines: “Herald patch” or “Christmas Tree” patch Koplik spots Severe pruritic rash, worse at night, between webs of toes and fingers, axillae, waistline, groin, breasts, butt, penis Rash appears in linear burrows – can last up to 4 weeks Capitis – head (most common) Pedis – foot Corporis/Circinata – body Cruris – jock itch Manuum – hands Barbrae – beard

Scabies

Sarcoptes scabiei

Tinea Infections – ringworm (Dermatophytosis)

yeast

Onychomycosis (tinea unguium)

Yeast

Yellow thickening of nail – great toe most common; nail bed may separate (onycholysis)

Inflammation of the sebaceous gland High androgen levels, bacteria, genetics

Open comedones (blackheads), closed comedones (whiteheads), small papules and pustules Affects face, chest and back Mild: <20 comedones; <15 inflammatory or <30 total Moderate: 20-100 comedones; 15-50 inflammatory or 30-125 Severe: > 5 cysts

Acne Vulgaris

Rosacea

Anthrax

Inflammatory response

Small acne-like papules and pustules around nose, mouth and chin. Patient blushes easily and ocular symptoms (dry eyes) Patient usually blonde, blue eyes “celtic background”

Bacillus anthracis

Cutaneous: begins as papule enlarges in 24-48 hour and develops eschar and necrosis. Hx of exposure of handling animals Pulmonary: inhaling aerosol through working with animals or bioterrorism – symptoms are flulike with cough, chest pain with cough, hemoptysis, dyspnea, hypoxia, shock

Diagnostics

Treatments

Concerns

Analgesic or NSAIDs Acyclovir for severe infections Avoid sharing personal items, gloves, towels.

Cover skin lesion until healed None – self-limiting (6-8 weeks) May need something for itching

Rule our secondary syphilis

Wet mount of scraped rash to view eggs under microscope

Permethrin 5% cream to entire body – wash off after 8-12h Treat everyone in household; clothes/bedding should be washed in hot water

Avoid Kwell due to neurotoxicity

KOH slide for hyphae and spores

OTC topical “azole” or allylamines (terbinafine, butenafine) Gold standard: griseofulvin (baseline LFT and repeat 2 weeks after initiating meds)

Fungal cultures of nail

Oral fluconazole 150-300mg weekly for 2-3 months; Lamisil weekly for several weeks; terbinafine

Mild: OTC - Neutrogena acne wash (salicylic acid 2%) plus benzoyl peroxide 2.5% Prescription meds: Isotretinoin (Retin-A), benzoyl peroxide with erythromycin (Benzamycin) cream, clindamycin topical (Cleocin) Mod: retinoid and antibiotic tetracycline, minocycline, doxycycline (if under 13 then erythromycin, clindamycin; Oral contraceptives: combined estrogenprogestin Yaz or Desogen Severe: Accutane; injections Baby acne – topical erythromycin or clindamycin First line: symptom control and avoidance of triggers (spicy food, alcohol, sunlight) Metronidazole topical gel (Metrogel); Azelaic gel (azelex); Low-dose tetracycline over several weeks

Cutaneous: doxycycline, ciprofloxacin, levofloxacin BID 7-10 days (if bioterrorism treat for 60 days) Post exposure prophylaxis: Cipro 500 mg BID x 60 days

Monitor LFTs

Teaching –take 6-8 weeks, put all over skin Before age 13 tetracycline can stain teeth permanently Accutane category X – females 2 forms of birth control – monitor liver lithium contributes to acne Rhinophyma: hyperplasia of tissue at tip of nose Ocular rosacea: blepharitis, conjunctival injection, lid margin telangiectasia

CARDIOVASCULAR SYSTEM

GRADING OF MURMURS

MURMURS ➢ ➢ ➢ ➢

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Turbulent blood flow through great vessels or across a heart valve Timing of murmur – systole or diastole Location of murmur – aortic or mitral Systolic murmurs – MR Peyton Manning AS MVP o Mitral Regurgitation- “pan systolic”/ holosystolic. Heard at apex, radiates to axilla, loud or high-pitched blowing (use diaphragm) o Physiologic Murmur▪ Hemic like in severe anemia, dehydration ▪ Becomes louder when lying down o Aortic Stenosis- second ICS to right of sternum, radiates to neck, harsh/noisy murmur (use diaphragm) – avoid physical exertion due to ↑ risk sudden cardiac death; monitored by 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 systolic click Diastolic murmurs – ARMS o Aortic Regurgitation- high-pitched, second ICS to right of sternum blowing (use diaphragm) o Mitral Stenosis- low pitched, apex of heard or apical area; also called “opening snap” “crescendo” (use bell) All diastolic murmurs – abnormal APETM (valve locations) o Aortic – 2nd ICS right upper border sternum o Mitral – apex or apical area of heart, PMI, 5th left IC space If radiates to axilla the mitral valve is closest to axilla If radiates to neck the aortic valve is closest to neck If a valve fails to open it is stenotic When a valve fails to close it is incompetent

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GRADE I/VI – barely audible GRADE II/VI – audible but faint GRADE III/VI – moderately loud, easily heard (as loud as S1) GRADE IV/VI – loud, associated with a thrill GRADE V/VI – very loud, heard one corner of the stethoscope off the wall GRADE VI/VI – loudest, heard without a stethoscope

STETHOSCOPE ➢ Bell – low tones (S3, S4), mitral stenosis ➢ Diaphragm – mid to high pitch tones, lung sounds, mitral regurgitation, aortic stenosis

HEART SOUNDS ➢ Motivated Apples o Motivated – systole – S1 closure of AV - mitral/tricuspid valve (lub) ▪ M (mitral valve) ▪ T (tricuspid valve) ▪ AV (atrioventricular valves) o Apples – diastole - S2 closure of semilunar - aortic/pulmonic valves (dub) ▪ A (aortic) ▪ P (pulmonic) ▪ S (semilunar) ➢ S3 - Pathognomic for CHF; possible normal for adolescent athletes and pregnancy; possible thyrotoxicosis; always abnormal if occurs >35yo “Kentucky” – best heard at pulmonic area (AKA ventricular gallop or S3 gallop) ➢ 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 ➢ Split S2 is best heard at pulmonic area – healthy athlete

CARDIOVASCULAR SYSTEM

ADDITIONAL PEARLES ➢ ➢

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FIBRINOLYSIS CONTRAINDICATION: ➢

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Absolute: prior intracranial hemorrhage, cerebral vascular lesion, neoplasm, ischemic stroke in last 3 months, aortic dissection, active bleeding, intracranial or intraspinal surgery within 2 months, severe uncontrolled HTN Relative: chronic uncontrolled HTN, significant HTN on presentation, ischemic stroke < 3 months, traumatic or prolonged CPR, major surgery within 3 weeks, recent internal bleeding within 2-4 weeks, non-compressible vascular punctures, pregnancy, active peptic ulcer disease, oral anticoagulant therapy

BP = HR x SV x PVR 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 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 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) 2nd chamber most likely to hypertrophy is left atrium Common pathologic murmurs to arise due to aging – aortic stenosis 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 Sudden unexpected finding on exam- how did I miss this in health history? o Onset o Location/radiation o Duration o Character o Aggravating factors o Relieving factors o Timing o Severity

CARIOVASCULAR SYSTEM

TARGET ORGAN DAMAGE: ➢

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Eye: hypertensive retinopathy with risk of blindness (silver, copper wire arterioles, AV nicking, flame shaped hemorrhages – black dots in visual field; papilledema) Kidney: microalbuminuria, proteinuria, ↑ creatinine, ↓ GFR, edema Cardiovascular: S3 (CHF), S4 (LVH), carotid bruits, CAD, MI, LVH, PAD or PVD Brain: TIA, CVA

JNC-8 GUIDELINES ➢ ➢

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LIFESTYLE MODIFICATION FOR HTN/DYSLIPIDEMIA: ➢ ➢ ➢

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Stop smoking. Reduce stress level.

Weight reduction if overweight/obese o 5-20mm hg per 10kg DASH eating plan o Fresh fruit/veggies. ↓sodium, ↑ K+, ↑ Ca; eat fatty cold-water fish 3x/wk.

Dietary sodium reduction – less than 2.4 g/day Aerobic physical activity o 40 min / 3-4 days per week Moderation of alcohol o Men < 2 o Women < 1

Implement lifestyle interventions Set BP goal o Anyone with diabetes or CKD < 140/90 o No diabetes or CKD ▪ <60 yrs. <140/90 ▪ >60 yrs. <150/90 Non-AA – thiazide or ACEI/ARB or CCB alone or in combination AA – thiazide or CCB alone or in combination CKD – ACEI or ARB alone or in combination with other class Maximize dose of 1st med or add 2nd med or start with combo drug.

THIAZIDE DIURETICS ➢ ➢ ➢ ➢ ➢ ➢

MOA: ↓ volume, venous pressure and preload Blacks get better results, associated with ED Favorable effect with osteoporosis or osteopenia High dose 25mg or more - potential for negative impact on glucose and dyslipidemia – hyperuricemia (gout), hyperglycemia Monitor Na+, K+, Mg++ depletion, calcium sparing (good for osteoporosis due to lower observed fx risk) HCTZ (contraindicated with sensitivity to sulfa drugs)

CALCIUM CHANNEL BLOCKERS “-IPINE” ALDOSTERONE ANTAGONIST DIURETICS ➢ ➢ ➢ ➢

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MOA: blocks aldosterone so ↑ elimination of Na+ and H20 in kidneys to conserve K+ Used for HTN, CHF, hirsutism, precocious puberty Adverse effect: Gynecomastia, hyperkalemia Avoid w/ potassium-sparing diuretics, ACEI or K+ supplements, renal insufficiency, DM2 w/ microalbumin Spironolactone (Aldactone) Eplerenone (Inspra)

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MOA: Systemic vasodilation, slows HR Most potent BP controlling med on the market o DHP (doesn’t hurt pulse) (↓ BP): amlodipine o Non-DHP (↓ HR and BP a little): diltiazem, verapamil 1st line choice in African American HTN Causes headaches, ankle edema, bradycardia, reflex tachycardia DO NOT USE: heart block, bradycardia, CHF Avoid grapefruit, macrolides Work better at night

LOOP DIURETICS ➢ ➢ ➢ ➢

ALPHA-1 BLOCKER “-OZIN” ➢ ➢

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ECG in therapeutic: prolonged PR, depressed, cupped ST segment ECG with toxicity: AV heart block Patients with toxicity have anorexia Drug interactions: amiodarone, diltiazem, macrolides, antifungals, cyclosporine and verapamil

Used for BPH and HTN First dose may cause orthostatic hypotension, dizziness, postural hypotension Give at bedtime, start low, titrate up.

Terazosin (Hytrin), Tamsulosin (Flomax) Carvedilol is both alpha/beta adrenergic antagonist

BETA-BLOCKERS – “-OLOL” ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

MOA: block beta1 receptors in heart Lowers heart rate and stroke volume Monitor for worsening asthma, COPD DO NOT USE: heart block, bradycardia USE: MI, migraines, glaucoma, resting tachycardia, angina, hyperthyroidism Whites get better systolic control than blacks – 4th line anti-HTN med Used more for heart failure and not BP Reduces effects of circulating catecholamines

ACEI “-pril” or ARB “-sartan” ➢ ➢

DIGOXIN

Furosemide (Lasix) Bumetanide (Bumex) Inhibits sodium-potassium-chloride pump of kidneys (↑ UO) Electrolyte imbalance, hypokalemia, hyponatremia, hypomagnesemia

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MOA: Block conversion of angiotensin I → II 1st choice in HTN with DM or renal disease Dry hacking cough, (more w/ACEI), hyperkalemia, angioedema Adjust dose in renal insufficiency AVOID in pregnancy, renal artery stenosis, acute renal insufficiency

CARDIOVASCULAR SYSTEM

OVERWEIGHT/OBESITY

DYSLIPIDEMIA ➢

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Screening and detection o Lipid profile in those with cardiovascular risk (DM, HTN, strong family hx and obesity) o 12 hours fasting ▪ Total cholesterol (TC) ▪ Low-density lipoprotein (LDL) ▪ High-density lipoprotein (HDL) ▪ Triglycerides (TC) Dietary options to ↓ LDL (5-10%) o Plant sterols – Take Control/Benecol margarine o Oatmeal, oat bran Reduce intake of saturated fat and cholesterol o Avoid trans fat o Total cholesterol < 200 Increase omega-2 fatty acids o Fish twice a week o Flaxseed, walnut, canola and soybean oils o If CHD, take 1-gram EPA + DHA (salmon 4oz daily or fish oil supplement use)

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BMI – ratio of weight to height o Weight (kilograms)/height (meters) o Muscular patients can have falsely elevated BMI Underweight < 18.5 Normal 18.5 to 24.9 Overweight BMI 25 to 29.9 Obese BMI > 30 o Male: waist circumference: >40 inches o Female: waist circumference: >35 o Waist-to-hip: 1.0 (males) o Waist-to-hip: 0.8 (females) Diagnosing metabolic syndrome o 3 characteristics: abd. obesity (weight circumference), HTN, hyperlipidemia or ↑ triglycerides and ↓ HDL (insulin insensitivity), fasting glucose > 100 or dx diabetes

STATIN THERAPY High-intensity Avoid in >80, impaired renal function, frailty, multiple comorbidities, with fibrate LDL reduction 50% Atorvastatin 40-80 Rosuvastatin 20-40

Moderate-intensity Preferred if high risk for adverse effects

LDL reduction 3049% Atorvastatin 10-20 Rosuvastatin 5-10 Simvastatin 20-40 Pravastatin 40-80 Lovastatin 40

Low-intensity Not recommended

LDL reduction <30% Pravastatin 10-20 Lovastatin 20 Simvastatin 10

ASCVD – high intensity LDL > 190 – high intensity Diabetes – moderate intensity 10 yr. ASCVD risk > 7.5% - moderate to high intensity **Not enough data of benefit > 75 Take at night with baby ASA

HMG-CoA INHIBITOR (STATIN) ↓ LDL 18-55% ↑ HDL 5-15% ↓ TG 7-30% Baseline hepatic enzymes – no further monitoring required Avoid grapefruit juice with simvastatin, atorvastatin, lovastatin Adverse effects: rhabdomyolysis, myositis • Risk factors for myositis (advanced age, low body weight and high-intensity statin therapy)

BILE ACID RESINS ↓ LDL 15-30% ↑ HDL 3-5% ↑ TG if > 400 Examples: cholestyramine, colestipol, colesevelam Adverse effects: constipation, ↓ absorption of other meds

NIACIN ↓ LDL 5-25% ↑ HDL 15-35% ↓ TG 20-50% Adverse effect: flushing (minimize by taking ASA 1-hour prior), hyperglycemia, hyperuricemia, upper GI distress, hepatotoxic

FIBRATES ↓ LDL 5-20% ↑ HDL 10-20% ↓ TG 20-50% Can cause ↑ in LDL with high TG Adverse effect: dyspepsia, gallstones, myopathy, do not use in severe renal/hepatic Ex: fenofibrate

FISH OIL (OMEGA 3) 4 gram/day ↓ TG 20-30% Adverse effect: ↑ risk of bleeding, GI upset due to fishy taste – freeze capsules, take with food, avoid hot beverages immediately after

SECONDARY HYPERTRIGLYCERIDEMIA Untreated/undertreated hypothyroidism Poorly controlled diabetes Excessive alcohol use

SELECTIVE CHOLESTEROL ABSORPTION INHIBITOR ↓ LDL 15-20% ↑ HDL 3-5% Examples: ezetimibe (Zetia) Generally used as add-on (Vytorin)

CARDIOVASCULAR SYSTEM

Name

Cause

Acute Coronary Syndrome: (STEMI, NSTEMI and unstable angina)

Unstable angina: vasoconstriction, nonocclusive thrombus, inflammation or infection

Congestive Heart Failure (Left sided)

MI, CAD, HTN, fluid retention, valvular abnormalities, arrhythmias

Signs/Symptoms

Midsternal chest pain, squeezing, tightness, crushing, heavy pressure, band-like, numbness/tingling left jaw/arm, diaphoresis w/ cool/clammy skin. Pain is provoked by eating heavy meal or exercise. Continues to have pain or discomfort at rest; Women present with fatigue, sleep disturbance, dyspnea, anxiety, weakness, back pain, nausea, syncope Lungs have crackles bibasilar and S3 heart sound Crackles, cough, dyspnea, dullness to percussion, paroxysmal nocturnal dyspnea, orthopnea, nonproductive cough and wheezing (“left = lung”)

Diagnostics

EKG

Chest x-ray, (Kerley B lines) EKG, CPK, troponin, BNP, CMP, echo

Treatments

Concerns

Beta-blockers, ACEI, aldosterone antagonists

STEMI – transmural MI with subsequent Q waves.

NSTEMI – subtotal occlusion Stable angina – pain is predictable.

Monitor weight daily, Avoid ETOH, stop smoking diuretics, ACEI or ARBs, beta-blockers if HFrEF, aldosterone antagonist Limit sodium intake (2-3 grams) Fluid restriction 1.5-2 L daily NYHA classify degree of physical disability Class I – no limitations Class II – activity results in fatigue, exertional dyspnea Class III – limitation in physical activity Class IV – symptoms at rest Antibiotic prophylaxis is no longer recommended for MVP, GU or GI Recommended for: Previous hx of endocarditis – dental procedures, prosthetic valves – resp. procedures, congenital heart disease Amoxicillin 2 grams PO Adult 1 hr. prior Amoxicillin 50mg/kg 1 hr. prior PCN allergic: Clinda 600mg, Biaxin 500mg, Keflex 2 grams,? macrolide

EF < 40% systolic failure (HFrEF) EF > 40% diastolic failure (HFpEF) Meds that contribute to heart failure: amlodipine, metoprolol (but they need it), actos/Avandia (glitazone), NSAIDs

MI, CAD, HTN, fluid retention, valvular abnormalities, arrhythmias

JVD (normal < 4cm), enlarged spleen, enlarged liver causing anorexia, nausea, and abdominal pain, lower extremity edema (“right = GI”)

Gm + Viridans streptococcus, staph aureus

Fever, chills, and malaise associated with new murmur and abrupt onset CHF Subungual hemorrhages, petechiae on palate, painful nodes on fingers or feet (Osler nodes), nontender red spots on palm/soles (Janeway lesions); fundoscopic exam Roth spots or retinal hemorrhages; hematuria

REFER to cardiologist Blood cultures x 3 CBC, Sed rate >20 mm/h

Pulsating-type sensation in abdomen or lower back pain. Sudden onset severe chest/back pain increasingly sharp and excruciating. Distended abdomen with hypotension

Abdominal ultrasound Incidentally: CXR may show widened mediastinum, tracheal deviation, obliteration of aortic knob

Surgical.

If less < 4cm monitor yearly with CT.

Cardiac Arrhythmias Atrial Fib

Risk factors: HTN, CAD, ACS, caffeine, nicotine, hyperthyroidism, alcohol intake, heart failure, LVH, PE, COPD, sleep apnea

May be asymptomatic; May be more than 110 bpm on palpation (if hemodynamically unstable – chest pain, hypotension, heart failure, cold clammy skin, acute kidney failure with new A Fib call 911

12-lead EKG TSH, electrolytes, renal function, 24h Holter monitor, echo Avoid stimulants

Search for underlying cause; Refer to cardiologist. CHA2DS2-VASC score > 2 needs anticoagulants CHF, HTN, Age > 75, Diabetes, Stroke/TIA, Vascular disease, Age 65-74, Sex (female); possible CCB, BB/digoxin to regulate HR Warfarin – A fib INR 2-3; Valves 2.5-3.5

Most common, classified as SVT – lead to stroke Paroxysmal AF: episodes terminate < 7 days

Paroxysmal Supraventricular Tachycardia (PSVT)

Digitalis toxicity, alcohol, Hyperthyroidism, caffeine, illegal drugs

Abrupt onset of palpitations, rapid pulse, lightheadedness, shortness of breath and anxiety HR range from 150-250bpm

EKG

Vagal maneuvers, carotid massage, ice water to face. If WPW or symptomatic call 911

May be seen in Wolf Parkinson White Syndrome

Congestive Heart Failure (right sided)

Bacterial Endocarditis

Dissecting Abdominal Aortic Aneurysm

Valvular destruction, myocardial abscess, emboli

Risk factors: male > 60, smoker, uncontrolled HTN, white race, genetic disease such as Marfan syndrome

INR >4-5 hold 1 dose and/or reduce maintenance dose

CARDIOVASCULAR

Name

Cause

Pulsus Paradoxus

Asthma, emphysema, tamponade, pericarditis, cardiac effusion

Hypertension

Any change in PVR or CO = change in BP

Signs/Symptoms

Apical pulse is audible even though radial pulse is no longer palpable. Measured through stethoscope and BP cuff. Chambers of heart are compressed causing exaggerated decrease in systolic BP <10mmHg Asymptomatic Normal < 120/80 Prehypertension <120-139/80-89 Stage I 140-159/90-99 Stage II >160/100 Secondary HTN: R/O < 30; severe HTN or acute rise in BP (previously stable), Resistant HTN (3 agents); malignant HTN Renal: renal artery stenosis, polycystic kidney, CKD Endocrine: hyperthyroidism, hyperaldosteronism (HTN, low K+, normal to elevated Na+), pheochromocytoma (labile ↑ BP with palpitations, anxiety, sweating, severe HA) Other causes: sleep apnea, coarctation of aorta

Diagnostics

Confirm 2 elevated BP on 2 visits >140/90 if <60yo 150/90 if >60yo and no comorbidities Kidneys: creatinine, GFR, UA Endocrine: TSH, fasting blood glucose Electrolyte: K+, Na+, Ca2+ Heart: cholesterol, HDL, LDL, triglycerides Anemia: CBC Baseline EKG and CXR

Treatments

Concerns

Hypertensive emergency diastolic BP > 120 with N/V, CVA/TIA, subarachnoid hemorrhage, MI, acute PE, acute renal failure, retinopathy, papilledema, acute severe low back pain (dissecting aorta)

Angiotensin I to II: ↑ vasoconstriction will ↑ PVR; younger pts have ↑ renin levels; alpha, beta and calcium channel blockers ↓ PVR; pregnancy system vascular resistance is lowered due to hormones

Isolated systolic HTN – systolic > 160 caused by loss of recoil in arteries ↑ PVR Thiazides, CCB, and/or ACEI/ARB

Stasis – prolonged bedrest or travel, CHF Coagulation disorders – Factor C deficiency, Leiden ↑ coagulation – contraceptives, pregnancy, fracture, trauma, surgery, malignancy

Deep Vein Thrombosis (DVT)

Thrombi developed from stasis, trauma, inflammation or coagulation

Gradual onset of swelling on lower extremity after prolonged sitting; painful, red, warm, swollen extremity. If PE abrupt onset chest pain, dyspnea, dizziness, or syncope

+ Homan’s sign (33% of pt.), CBC, platelets, PT/PTT, INR, d-dimer, chest x-ray, EKG ultrasound

Refer Wells Criteria Warfarin takes effect in 3-5 days INR 2-3 with DVT Clarithromycin ↑ effects of warfarin Cholestyramine ↓ effects of warfarin Direct Thrombin inhibitor (Pradaxa)

Superficial Thrombophlebitis

Inflammation of superficial vein from trauma/secondary infection (S. Aureus)

Acute onset of indurated vein (localized redness, swelling and tenderness). Usually located on extremities. Afebrile and normal vital signs

Indurated cordlike vein that is warm and tender to touch without swelling or edema

NSAIDs, warm compresses, elevation of limb

Peripheral Artery Disease (PAD)

Narrowing or occlusion of medium to larger arteries in lower extremities (arterial insufficiency)

Worsening pain on ambulation instantly relieved by rest (claudication – angina of calf muscles) Thin skin, hairless toes, toenails are often thick and discolored, possible gangrene of toes; decreased to absent dorsal pedal pulse

Check pedal and posterior tibial pulses, ABI < 0.9 Doppler US flow study Refer to vascular

Smoking cessation, daily ambulation exercises Cilostazal (Pletal) – vasodilator can be used with ASA or Plavix (caution if grapefruit juice, diltiazem and omeprazole taken together) Pentoxifylline (Trental) – effect is marginal

Foot gangrene, CAD, carotid plaquing ↑ risk with HTN, smoking, diabetes, HLD Can lead to osteo

Reversible vasospasm of peripheral arterioles of fingers/toes

Chronic color changes on fingertips white (pallor), blue (cyanosis), red (reperfusion); numbness and tingling. Can last for several hours ↑ risk of autoimmune disorders: thyroid, pernicious anemia, RA More common in females 8:1; scleroderma secondary to Raynaud’s

Check distal pulses

Avoid cold objects, cold weather and stimulants, avoid smoking CCB (Nifedipine or amlodipine) or ACEI Avoid vasoconstricting drugs, no BB

Small ulcers in fingertips/toes Occurs between 15 and 45 yrs. of age

Raynaud’s Phenomenon

CARDIOVASCULAR

Name

Mitral Valve Prolapse

Hyperlipidemia

Rhabdomyolysis

Cause

Systolic murmur

Risk factors: HTN, premature heart disease (women < 65 and men < 55) DM, dyslipidemia, low HDL, cigarette smoking, obesity, microalbuminuria, CAD, PAD

Acute breakdown of skeletal muscle, acute renal failure

Nonalcoholic Fatty Liver Disease (NAFLD) (Fatty Liver)

Triglyceride fat deposits in liver

Varicose Veins

Inherited venous defect, leg crossing, wearing constrictive garments, prolonged standing, heavy lifting

Signs/Symptoms

Fatigue, palpitations, chest pain, lightheadedness aggravated by heavy exertion; May be asymptomatic; associated with pectus excavatum, hypermobility of joints, arm span greater then height (Marfan’s syndrome) Total cholesterol: Normal: less than 200 Borderline: 200-239 High: greater than 240 HDL: greater than 40 (low HDL is generally from ↑ carb and ↓fat diet) LDL: less than 100 Triglycerides: less than 150 – pancreatitis associated with > 1000 (if triglycerides are > 500 treat triglycerides first – fenofibrate, niacin, lovanza) (avoid alcohol and Tylenol; could be metabolic syndrome, DM, familial, alcohol abuse, hyperthyroidism, kidney disease, medications

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Treatments

Concerns

S2 “click” – mid to late systolic murmur Cardiac echocardiogram with doppler flow study

Asymptomatic needs no treatment MVP w/ palpitations tx with BB, avoid caffeine, alcohol and cigarettes. Holter monitoring can be used to determine arrhythmias

↑ risk thromboemboli, TIA, AF and ruptured chordae tendineae

Exercise, lose weight, eat healthy fats, eliminate trans fats, decrease junk food, stop smoking, DASH diet Fasting lipids starting at age 20 (and every 5 yrs.) >40 screen every 2-3 yrs.

If HLD: screen at least annually

CK, urinalysis (myoglobinuria/proteinuria), BUN, creatinine, potassium, EKG

Usually asymptomatic; may have hepatomegaly If symptomatic, fatigue and malaise with RUQ pain. Associated with obesity, metabolic syndrome, DM and HLD

Annual labs show increase of ALT and AST, negative hepatitis A, B, C.

Tortuous dilated superficial veins; leg aching, mild edema at the end of the day and in warm weather most often great saphenous vein affected

First Degree AV Block: prolonged PR>0.2 seconds o If the R is far from P – FIRST DEGREE Second Degree Type I (Wenckebach): PR is progressively longer until it drops o Longer, Longer, Longer, drop then you have WENCKEBACH Second Degree Type II: PR constant but drops QRS periodically o If a QRS don’t get through, then you have MOBITZ II Third Degree: complete, no pattern between PR and QRS o If Ps and Qs don’t agree, then you have THIRD DEGREE

Target is to lower LDL first unless ↑ triglycerides (>500) – STATINS Triglycerides are raised by alcohol and sugar Simvastatin interactions: grapefruit, fibrates, antifungals, macrolides, amiodarone

Monitor for myalgias Consider stopping cholesterol at age 80 if symptoms, but statins are excellent at keeping atherosclerosis stable so can prevent MI or CVA

Statins can cause memory loss, confusion.

Triad of muscle pain, weakness and dark urine Muscle pain and aches persistent without associated muscular exertion

HEART BLOCK ➢

Diagnostics

Weight loss, diet Discontinue alcohol, avoid hepatotoxic drugs (acetaminophen, statins) REFER GI for Liver biopsy (gold standard) ***can progress to cirrhosis

Risk factors: obesity, diabetes, metabolic syndrome, HTN, certain drugs Most common liver disease in US - #1 reason for liver transplants

Laser venous ablation, sclerotherapy, surgery

Women are affected 2x as much as men

PULMONARY SYSTEM

PNEUMONIA - CURB 65 Confusion of new onset Blood Urea nitrogen > 19 Respiratory rate > 30 Blood pressure diastolic < 90 or systolic < 60 Age 65 or older

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ASTHMA LAMA LABA ICS -ium & terol one glycopyrrolate ide SABA (beta2 agonist) How often? 1-2x/wk.

More often (add) Less often (drop)

INHALED MUSCARINIC ANTAGONIST

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ASTHMA/COPD

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Pneumonia causes increased right sided heart workload which can be a heart failure trigger in the older adult

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Intermittent Asthma (FEV1 > 80% P) o Symptoms < 2 days week Mild (FEV1>80% Predicted) o Symptoms > 2 days week, but not daily o Night time 3-4/month o Minor limitation Moderate (most common) 60-80%P o Symptoms daily o Night time > 1x week o Some limitation Severe (FEV1<60% Predicted) o Symptoms throughout day o Night time often 7x week o Extreme limitation

PHYSICAL EXAM FINDINGS

CURB-65 Results: 0-1: treat as outpatient 2: consider short stay in hospital or watch very closely as outpatient 3-5: Requires hospitalization with consideration as to whether patient needs to be in the intensive care unit.

COPD

RANDOM PEARLS

Emerging role in asthma Well established in COPD (offer protracted duration) Used for prevention, not treatment (use scheduled) o SAMA - Ipratropium bromide (Atrovent) ▪ bronchodilation o LAMA - Tiotropium bromide (Spiriva); umeclidinium (Ellipta) Anticholinergic – can contribute to worsening BPH o If occurs switch from LAMA to LABA such as salmeterol

Normal chest percussion sound: resonance Lower lobes: vesicular breath sounds & upper lobes: bronchial Consolidation o Dullness to percussion o Increased tactile fremitus (have pt. say 99) o Bronchial or tubular breath sounds, often with late inspiratory crackles that do not clear with cough o Egophony: “eee” sounds like ah Pleural inflammation o Sharp, localized pain, worse with deep breath, movement, cough o Audible pleural friction rub (sounds similar to stepping in fresh snow) – heard on inspiration & expiration Air trapping o Hyperresonance o ↓ tactile fremitus o Wheeze (exp. first, insp. later) o Low diaphragms o ↑ AP diameter

CLASSIFICATION ➢

➢

➢

INHALED CORTICOSTEROIDS (ICS) STEP WISE

➢ ➢

Preferred controller tx for persistent asthma Requires constant daily use for optimal effect Low dose Medium dose Beclomethasone 80-240mcg >240(QVAR) 480mcg Budesonide 180>540(Pulmicort) 540mcg 1080mcg Fluticasone (Flovent) 88-264mcg 264-440mcg Mometasone 100300-500mcg (Asmanex) 300mcg

➢ High dose ➢ >480mcg

➢

>1080mcg >440mcg >500mcg

➢

➢

INHALED CORTICOSTEROIDS/LONG ACTING BETA2 AGONIST (ICS/LABA) ➢

LEUKOTRIENE MODIFIER ➢ ➢

Additional benefit with allergic rhinitis, most often in conjunction with ICS Requires consistent daily use for optimal effect o Montelukast (Singular)

➢ ➢

Preferred controller tx for moderate to severe persistent asthma BLACK BOX: ↑death in asthma patients using LABA Requires consistent, daily use for optimal effect o Budesonide + formoterol (Symbicort) o Fluticasone + salmeterol (Advair) o Mometasone + formoterol (Dulera)

Intermittent Asthma o SABA Step 2 o Low dose ICS Step 3 o Low dose ICS + LABA or o Medium dose ICS Step 4 o Medium dose ICS + LABA and consider omalizumab for allergies Step 5 o High dose ICS + LABA + oral corticosteroid and consider omalizumab for allergies

PDE-4 INHIBITOR ➢ ➢

Roflumilast (can induce psychosis) Minimizes risk of COPD exacerbation

PULMONARY SYSTEM

COPD: FEV1/FVC < 70 ➢

Dramatically increases right sided heart workload

In patients with FEV1/FVC<0.70 GOLD 1 Mild FEV1 > 80% predicted GOLD 2 Moderate 50% < FEV1 < 80% predicted GOLD 3 Severe 30% < FEV1 < 50% predicted GOLD 4 Very severe FEV1 < 30% predicted First Line therapy: ➢ GOLD 1-2: (don’t commonly see in clinic) o <1 exacerbation per year o Low risk: SAMA or SABA prn o High risk: LAMA or LABA set schedule ➢ GOLD 3-4: o >2 exacerbation per year o ICS + LABA or LAMA on set schedule ****LAMA + ICS with LABA (commonly used) ➢ Effective use of long-term oxygen requires at least 15 hours a day ➢ Beta agonist – stimulant or bronchodilation o (beta1 heart) (beta2 lung) ➢ SABA (4 hrs.) / LABA (12 hrs.)– palpitations, tachycardia. Use caution in HTN, angina and hyperthyroidism. Avoid combining with caffeinated drinks. ➢ Anticholinergics – (prevent bronchoconstriction) tropium avoid if patient has narrow-angle glaucoma, BPH or bladder neck obstruction ➢ Exacerbations – Corticosteroids with possible antibiotics

THEOPHYLLINE ➢ ➢

Risk factors for fatality o Hx of ED visits o Frequent use of rescue inhaler o Nocturnal awakenings o Increased dyspnea and wheezing o Respiratory viral infection

PNEUMONIA ➢ ➢

Young otherwise healthy – atypical pathogen o Macrolide or doxycycline Complicated o Fluoroquinolone o Macrolide plus beta-lactam

➢

PPSV23 o 19-64 asthma, COPD, CVD, smoker o Age 65+ PCV13 o 19-64 with asplenia, immunocompromised o Age 65+

➢

Tachypnea is most common presentation

SPIROMETRY ➢ ➢

➢

Obstructive dysfunction: (reduction in airflow rates) o Asthma, COPD, bronchiectasis Restrictive dysfunction: (reduction of lung volume due to decreased lung compliance) o Pulmonary fibrosis o Pleural disease o Diaphragm obstruction Not recommended during exacerbation

PULMONARY EMBOLISM

CHEST X-RAY PEAK EXPIRATORY FLOW: PEF ➢

PEF is based on HAG o Height o Age o gender

COUGH ➢ ➢

ASTHMA ➢

Bronchodilator Used on daily set schedule

PNEUMOCOCCAL VACCINES ➢

➢

How long have you coughed?

Acute < 3 weeks o Acute respiratory infection o Exacerbation of COPD, asthma o Pneumonia o PE Chronic > 8 weeks o Asthma o GERD o Pertussis, atypical pneumonia o ACE inhibitors (begins 1-2 weeks after starting med) o Chronic bronchitis o Bronchiectasis o Lung cancer

➢ ➢ ➢

PA – x-ray goes through back AP – x-ray goes through front of chest Air: appears black (low density so less absorption) ➢ Bones: appears white ➢ Metals: bright white (high absorption) ➢ Tissue: Different grayish shades (medium absorption) ➢ Fluid: Grayish to whitish ➢ Tissues visible: trachea, bronchus, aorta, heart, lungs, pulmonary arteries, diaphragm, gastric bubbles, ribs ***Unilateral finding on lung exam warrant CXR ***Hilar nodes require follow-up

CHRONIC STEROID USE ➢

➢ ➢ ➢ ➢ ➢

Osteoporosis o Calcium with Vitamin D 1200mg for menopausal women Growth failure in children Glaucoma Cataracts Immune suppression Hypothalamic-pituitary-adrenal suppression

PULMONARY SYSTEM

PULMONARY SYSTEM

Name

Cause

Signs/Symptoms

Pulmonary Emboli

Hx of A fib, estrogen therapy, smoking, surgery, cancer, pregnancy, long bone fractures and prolonged inactivity

Sudden onset dyspnea and coughing. Cough may be productive of pink-tinged frothy sputum. Tachycardia, pallor and feelings of impending doom

Impending Respiratory Failure - Asthmatic Exacerbation

COPD – can include chronic bronchitis and emphysema

CommunityAcquired Pneumonia (CAP)

Atypical Pneumonia

Acute bronchitis

Pertussis “whooping cough”

Tachypnea, tachycardia or bradycardia, cyanosis and anxiety. Patient appears exhausted, fatigued, diaphoretic and uses accessory muscles to help with breathing.

Alveolar damage from loss of elastic recoil of lungs, exposure of irritants Airflow limitation

Strep pneumoniae; H. influenzae; Mycoplasma; Chlamydophila pneumonia; Cystic fibrosis: Pseudomas aeruginosa (Gm-) Mycoplasma; Chlamydophila pneumonia; Legionella

Chronic cough (2 years), chronic sputum production, shortness of breath worse with physical exertion, progressive symptoms, barrel chest, weight loss; hyperresonance upon percussion, tactile fremitus and egophony is decreased; CXR may show hyperinflation; bullae sometimes present; coarse crackles Alpha-1 antitrypsin deficiency screening < 45yrs ** pack year smoker – COPD**

Sudden onset high fever w/ chills, productive cough and purulent sputum (rust-colored if strep pneumo). c/o pleuritic chest pain w/ coughing and dyspnea Rhonchi, crackles or wheezing with dullness over affected lobe, ↑ tactile fremitus and egophony; abnormal whispered pectoriloquy Fatigue w/ paroxysmal coughing that’s nonproductive; gradual onset starting like a cold; most continue to work/school regardless of symptoms Wheezing with diffuse crackles/rhonchi, rhinorrhea, erythematous throat

Diagnostics

Treatments

Cyanosis and quiet lungs.

May speak in 1-2-word sentences

Epi stat. 911 oxygen, albuterol nebs, parenteral steroids, antihistamines and H2 blocker

Spirometry FEV1/FVC <0.70 postbronchodilation.

Classification of severity determined by FEV1 CXR only when trying to R/O pneumonia

Chest x-ray-lobar consolidation (note: middle lobe is anterior chest by nipple) CBC: leukocytosis (>10.5) look for anemia

Smoking cessation, pneumonia & flu vaccine, Acute exacerbation: SABA, LABA, ICS Acute prednisone 40mg/day x 5-10 days **↑ dyspnea, ↑ sputum volume & purulence may need antibiotic; higher risk for Strep pneumonia & H. influenzae –Augmentin (avoid due to GI upset) Cefdinir, macrolide (avoid due to CV risk); resp. fluoroquinolone (↑ tendon rupture)

S. pneumoniae: macrolides, doxycycline, DRSP: high dose amoxicillin, resp. fluoroquinolones.

Minimum 5 days (most 5-7 days) No comorbidities: Macrolides, doxycycline Comorbidities: resp. fluoroquinolones, or macrolide plus beta-lactam

Concerns

High risk: > 2 exacerbations in last year, FEV1 < 50%, hospitalized for COPD in past year **rarely see under age 40 Chronic bronchitis: cough with excessive mucous for 3+ months for 2+ years Complex patients with co-morbidities: Multiple meds, drugdrug interactions, drugdisease interactions Flu vaccine > 50yo Pneumo vaccine >65yo Smokers – H. Influenza S. pneumoniae affects young and old Lung cancer can present as recurrent pneumonia

Physical, chest x-ray shows diffuse infiltrates, CBC

Macrolides, resp. fluoroquinolones, doxycycline; antitussives, fluids/rest

***Legionella – contaminated by inhaling mist from a water source.

Also accompanied by GI Exacerbation of asthma Pneumonia from secondary infection ***On rare occasion macrolide or doxycycline Complications: Sinusitis, OM, pneumonia, fainting, rib fractures

Virus causing inflammation of Upper respiratory tract

Sudden onset new cough that’s dry and possible small amts sputum; frequent paroxysms of coughing, possible low-grade fever, wheezing and chest pain w/ cough; cough keeping him awake at night

History, possible chest x-ray

Symptomatic: dextromethorphan, Tessalon PERLES, guaifenesin, severe wheezing Atrovent or albuterol inhaler consider steroids 40mg for 3-5 days

Bordetella pertussis bacteria (Gm -)

Cough lasting longer than 14d with 1 of following: paroxysmal coughing, inspiratory whooping w/o cause. Can last months. 3 stages: catarrhal, paroxysmal, convalescent. Most infectious early in disease

Nasal swab for culture and PCR Pertussis antibodies by ELISA CBC: lymphocytosis (80% lymphocytes in WBC)

1st line: macrolides Chemoprophylaxis for close contacts Respiratory precautions Antitussives, mucolytics, rest and hydration Tdap booster > 11yo

PULMONARY SYSTEM

Name

Tuberculosis

Asthma

Cause

Signs/Symptoms

Mycobacterium tuberculosis

Fever, anorexia, fatigue, night sweats, cough. As progresses, productive cough w/ hemoptysis and unexplained weight loss

Chronic inflammation of bronchial tree Reversible disease

Recurrent cough, wheeze (end expiration), shortness of breath and/or tightness of chest due to variable airflow obstruction and bronchial hyperresponsiveness triggered by underlying airway inflammation (predictable pattern of symptoms) Symptoms worse at night or with exercise, viral infections or exposure to smoke Typical early in life onset Triad: wheeze, cough and chest tightness/SOB

LUNG CANCER SCREENING ➢ ➢

➢

Diagnostics

Symptoms: o Chest discomfort, dyspnea, hemoptysis, cough High risk patients o Age 55-74 who smoked at least 30 pack year and/or have quit in last 15 yrs. o High risk smokers at age 50 Current limitations include: o High false-positive rate o Radiation exposure from multiple CT scans o Patient anxiety

Mantoux test: >10mm QuantiFERON or T-SPOT IGRA (avail w/in 24h) Sputum – early morning and collect for 3 days – NAAT, C&S and AFB CXR: affects upper lobes

↑ FEV1 > 12% using spirometry; Height, age, gender PFT measures effectiveness of treatment and exacerbations

Asthma X X

NEVER!!

X X

Treatments

Concerns

Report to health department Mantoux positive if induration>5mm: HIV+, recent contact, CXR w/ previous TB disease, Immunocompromised >10mm: immigrants, child less than 4, IV drug users, health care workers, homeless; employees of jails, nursing homes >15mm: person w/o risk Isoniazid (INH) 300mg daily, rifampin, ethambutol and pyrazinamide 3x a week (check baseline liver functions)

Risk factors: HIV, migrants, homeless, inmates and nursing homes Prior BCG vaccine may cause false positive Ethambutol causes optic neuritis – avoid if abnormal vision

Rescue meds: SABA long-term control: inhaled corticosteroids Step-up therapy if not controlled; Acute prednisone 40-60mg/day x 3-10 days Written Asthma action plan; PEAK flow is used to monitor Well controlled – F/U 3-6 months Not well controlled 2-6 weeks **See all asthmatics in Sept to get on controlled drugs and immunizations

COPD Consider steroid first for treatment Anticholinergics are not usually helpful Disease is progressive LABA alone is safe Steroid alone is safe Needs rescue inhaler

X X

X

Consider bone density for those on long-term steroids Treatment Goals: Perform normal activities Minimal to no exacerbations Minimal use of rescue inhaler (<2 days a week) Avoid ED Maintain normal PFT

ENDOCRINE SYSTEM

WHEN TO USE INSULIN All Type 1 DM patients Basal insulin with adjustments for meals - Basal 40-50% total daily insulin - Bolus 50-60% total daily insulin, given in response to carb intake post meals and with snacks (2 Units to 15 carbs Type 2 DM patients - At time of diagnosis to achieve initial glycemic control if A1c >9% o Short course 2-3 weeks - A1c > 10% - When > 2 standard agents are inadequate - Start 0.1-0.2 u/kg or 10 units - Adjust 2-4 u (or 10-15%) 1-2x weekly to reach FBG goal (80-130 in am) - If hypoglycemia – decrease by 4 units (10-20%) - If am is reached, but during the day it spikes – o Basal Plus: short acting insulin before biggest meal of day o Basal Bolus: bolus at each meal

DIABETIC MEDICATIONS FOR DM ➢ ➢

➢

➢

➢

INSULINS Onset 15 min

Peak 30 min – 2.5 hr.

Duration 4.5 hrs.

Short acting (Regular) Intermediate NPH Basal (Lantus Levemir)

30 min

1-5 hrs.

6-14 hrs.

None

6-8 hrs.

Mixture 70/30

30 min.

Rapid acting (Lispro, Aspart)

1 hr.

1 hr.

4.4 hrs.

18-24 hrs.

24 hrs.

Levemir usually BID 24 hrs.

➢ ➢

➢

Consider what therapeutic goal is? Correction of fasting glucose, postprandial glucose, action on insulin resistance, increasing insulin availability, offloading of glucose? Hypoglycemia risk? Cost? Adverse effects?

BIGUANIDE – insulin sensitizer, ↓ hepatic glucose production and intestinal glucose absorption. Action on fasting & postprandial. Minimal to NO hypoglycemia when used alone. o Metformin/Glucophage (1500-2000/day prevention) ▪ A1c reduction 1-2% ▪ Contraindicated: eGFR < 45, acidosis, alcoholic, hypoxia, Active liver disease (hep C), heart failure • FYI – can use 1000mg daily for GFR 30-45 – don’t start them on it, but can continue ▪ ↑ B12 deficiency (after on meds > 5 yrs.) – ok to give in Stage 1 Heart Failure ▪ Risk of lactic acidosis (rare) ▪ Hold if IV contrast dye testing for 48h ▪ Side effects: diarrhea, flatulence and nausea THIAZOLIDINEDIONE (TZD) – insulin sensitizer. Action on fasting & postprandial. Minimal to NO hypoglycemia used alone. o Pioglitazone (Actos), Rosiglitazone (Avandia) – monitor ALT ▪ A1c reduction 0.7% ▪ Avoid heart disease/CHF, causes edema, rare risk of bladder cancer, liver toxicity, weight gain, fractures SULFONYLUREA – stimulates b-cells to secrete insulin – Action on fasting & postprandial. HYPOGLYCEMIA RISK o Glipizide (Glucotrol)**preferred over glyburide in older adult, Glyburide (Diabeta) **long half-life; BEERS criteria avoid, Glimepiride (Amaryl) - cheap ▪ 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 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% o Sitagliptin (Januvia), Saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina) – weight neutral, oral agents o Pancreatitis risk and unexplained joint aches MEGLITINIDE – minimize postprandial hyperglycemia; Repaglinide (Prandin) and Nateglinide (Starlix) GLP-1 AGONIST – ↑ insulin release, largely in response to ↑blood glucose post meal. Action largely on postprandial. Minimal hypoglycemia, expensive. Injection only. o A1c reduction 1-1.5% o Exenatide (Byetta, Bydureon), liraglutide (Victoza), albiglutide (Tanzeum), dulaglutide (Trulicity) o Slows gastric emptying, leading to appetite suppression and possible weight loss o N/V, contraindicated in gastroparesis, rare pancreatitis risk, avoid in severe renal impairment or ESRD SGLT2 INHIBITOR – lower plasma glucose by ↑ amount of glucose excreted in urine. Primarily postprandial effect.

HYPOGLYCEMIA RISK when used with insulin and insulin secretagogues (Sulfonylurea, DPP-4 inhibitor, GLP-1 agonist) o A1c reduction 0.7-1% o Canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance) – weight loss, lowers BP o ↑ risk GU infection adjust dose in renal impairment, DKA and urosepsis risk

ENDOCRINE SYSTEM

ADDITIONAL DIABETES CONSIDERATIONS ➢

➢ ➢

➢

➢

➢ ➢

A – Aspirin (81-162 mg daily) in most, esp. men > 50 and women > 60 with DM and > 1 additional CVD risk factor such as HTN, smoking, family hx B – BP controlled > 2 agents including ACEI/ARB and thiazide C – Cholesterol: statin therapy > 40 or hx ACS. Goal Lipids < 100 Creatinine (renal function): serum creatinine, calculated GFR and urine microalbumin annually D – Diet: limit trans and saturated fat. Schedule with dietician if needed Dental care: reinforce E – Exercise: > 150 min/week (walking) + resistance exercise 3x week Eye exam: annually (diabetic retinopathy) o Neovascularization (new growth of fragile arterioles in retina), microaneurysms, cotton wool spots, soft/hard exudates F – Foot exam: visually every visit & monofilament at minimum annually G – Goals of care

ENDOCRINE FACTS ➢ ➢ ➢ ➢

➢ ➢ ➢

SOMOGYI EFFECT ➢ ➢ ➢ ➢

Severe nocturnal hypoglycemia stimulating glucagon to be released from the liver High FBG by 7:00a, usually due to overtreatment with evening or bedtime insulin – more common in Type 1 Diagnosed by checking glucose at 3am for 1-2 weeks Tx: Snack before bedtime or eliminate/lower bedtime NPH/regular insulin

DAWN PHENOMENON ➢

Elevation in FBG daily early in morning from increase in insulin resistance between 4 and 8am caused by spike in GH and glucagon

➢

Endocrine works as negative feedback – low level of active hormone stimulates production.

Hypothalamus stimulates anterior pituitary gland into producing stimulating hormones (FSH, LH, TSH) – these hormones tell organs to produce hormones.

Hypothalamus: coordinates nervous and endocrine system by sending signals, produces neurohormones that stimulate or stop production Pituitary Gland: Hypothalamus TRH, GnRH, CRH, GHRH, Somatostatin “On or Off” Switch Released by Anterior Pituitary TSH, FSH, LH, GH, ACTH, MSH, Prolactin, Vasopressin, and Oxytocin Target Organs Thyroid (TSH): T3 and T4 (thyroxine) – free or bound (no impact on metabolism) Ovaries/Testes (FSH/LH): estrogen, progesterone, androgens, testosterone Adrenal Cortex (ACTH): glucocorticoids, mineralocorticoids Body (GH): somatic growth Uterus (oxytocin): uterine contractions, bonding Kidneys (vasopressin): blood volume Pineal (melatonin): circadian rhythm Breast (prolactin): milk production Posterior pituitary: secretes antidiuretic hormone and oxytocin which are made by hypothalamus and stored and secreted by posterior pituitary Thyroid gland: uses iodine to produce T3 (huge impact on metabolism – 5x) and T4 (small changes affect TSH) Parathyroid glands: produce PTH which is responsible for calcium balance of body by regulating calcium loss or gain from bones, kidneys and GI tract Pineal gland: pea-sized gland in brain that produces melatonin.

RANDOM OBESITY PEARLS ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

Orlistat – take within an hour of each meal that contains fat Belviq – avoid with medications that have serotonergic effect Phentermine – teratogenic effects Serotonin is responsible for the sensation of satiety 1 pound of fat contains 3500 calories 10,000 steps is = 4-5 miles Weight loss meds: if not achieved 5% weight loss by week 12, discontinue therapy Weight loss of 10%+ yields immediate reduction in death from cardiovascular and cerebrovascular disease 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 Obesity can lead to OSA, steatohepatitis, female infertility and endometrial cancer

ENDOCRINE SYSTEM

THYROID

WEIGHT CHANGE STOOL PATTERN

HYPOTHYROID Thick, dry “hung up” patellar reflex, slow arc out, slower arc back, overall hyporeflexia “can’t make sense, thoughts too slow” Small gain 5-10 lbs.

Constipation

MENSTRUAL ISSUE HEAT/COLD INTOLERANCE OTHER

Menorrhagia Easily chilled Hypertriglyceridemia

SKIN REFLEXES

MENTATION

HYPERTHYROID Smooth, silky Hyperreflexia

“Can’t make sense, mind racing” Loss ~ 10 lbs.

Frequent, low volume, loose Oligomenorrhea Heat intolerance Proximal muscle weakness Tachycardia, HTN

THYROID NODULE ➢

Solitary Thyroid Nodule

o Palpable thyroid mass > 1 cm in diameter o 5% chance of malignancy ➢ Malignant Thyroid Nodule o Hx head or neck irradiation o Size > 4 cm o Firmness, Nontender on palpation o Relatively fixed position (non-mobile) o Persistent Nontender cervical lymphadenopathy o Dysphonia o Hemoptysis ➢ TSH, Thyroid ultrasound o ↑TSH – metabolically inactive (most common) ▪ Fine needle aspiration biopsy (refer) • Most cost effective o ↓TSH – metabolically active ▪ Nuclear med thyroid scan • Hot – metabolically active o radioactive ablation or surgery • Not hot – metabolically inactive o Fine needle aspiration o Cold usually cyst

TOXIC ADENOMA ➢ ➢

Benign, metabolically active thyroid nodule Autonomously functioning adenoma: Painless thyroid nodule with undetectable TSH

THYROID ➢

➢

➢

➢

Untreated hypothyroidism, inadequate thyroxine dose • ↓ Free T4 = ↑ TSH Untreated hyperthyroidism • ↑ Free T4 = ↓ TSH ➢ ➢

HYPERPARATHYROIDISIM ➢

➢ ➢ ➢

Common cause in asymptomatic patient with hypercalcemia ↑ Calcium and PTH ↓ phosphorus ↓ potassium

Thyroid-stimulating hormone (TSH) NL 0.4-4.0 (goal 1.2) o Evaluates hypothalamic-pituitary function ▪ Anterior pituitary ability to detect circulating free thyroxine o When TSH normal, thyroid disease ruled out Free T4 (free thyroxine) o Unbound, metabolically active portion of thyroxine o F/U test to confirm, support dx of hypo or hyperthyroidism with abnormal TSH Thyroid peroxidase antibody (TPO Ab) o Test to help detect autoimmune thyroid disease o Measures antibody against peroxidase Total T4 (total thyroxine) o Reflects the total of the protein-bound and free thyroxine o (useless – altered with medications, clinical conditions)

➢ ➢ ➢

Drugs that affect thyroid: Lithium, amiodarone, high doses of iodine, interferon-alfa, dopamine (lithium can damage thyroid) Natural thyroid contains fixed doses of T3 and T4 and has different pharmakinetics than levothyroxine Excessive use of levothyroxine includes bone thinning Periodic routine screening is recommended with Down Syndrome Hypothyroidism - ↑ LDL, hyponatremia, ↑ MCV, ↑ CK

BETA BLOCKERS ➢ ➢

Beta-adrenergic antagonist with beta 1 blockade o 1 heart Beta-adrenergic antagonist with beta 1 blockade o 2 lungs, 2 arms, 2 legs (tremors)

ENDOCRINE

Name

Cause

Signs/Symptoms

Thyroid Cancer

↑ risk with radiation therapy from childhood cancer (Wilms tumor, lymphoma, neuroblastoma) or lowiodine diet; family hx of thyroid cancer

Single thyroid nodule usually in upper half of one lobe, may be accompanied by enlarged cervical nodes. May complain of hoarseness and dysphagia.

Pheochromocytoma

Random episodes of headache (mild to severe) diaphoresis, tachycardia, HTN. Episodes resolve spontaneously. Pt’s vitals are normal in between attacks.

Hyperprolactinemia

Sign of pituitary adenoma.

Slow onset. Women may present with amenorrhea. Galactorrhea in both males and females. When tumor is large enough, pt. will complain of headaches and vision changes.

Hyperthyroidism (thyrotoxicosis)

Hypothyroidism

Graves’ disease most common cause

Tachycardia, rapid weight loss, irritability, anxious, hyperactivity, insomnia, possible HTN, a fib or PAC, sweaty, exophthalmos, diarrhea, amenorrhea, heat intolerance, fine tremors, brisk deep tendon reflexes, CHF. goiter

Hashimoto’s (autoimmune), postpartum, and thyroid ablation with radioactive iodine

Fatigue, weight gain, cold intolerance, constipation, menstrual abnormalities, alopecia on outer 3rd of eyebrows, may have ↑ cholesterol.

May have atrial fib.

Myxedema may have poor thinking/memory, hypotension, hypothermia Symptoms are very variable

Addison’s Disease

Primary: ↓ cortisol and sometimes aldosterone produced by adrenal glands Secondary: pituitary gland is diseased

Cushing’s

↑ levels of cortisol for extended period (long term steroid use) or overproduction of ACTH; pituitary tumor

Symptoms vary and develop over months. Chronic diarrhea, N/V, loss of appetite, paleness or darkening of the skin with a possible patchy appearance, muscle fatigue, weakness, slow or sluggish movement, hypoglycemia, low BP, fainting and salt craving. During crisis, symptoms appear suddenly Progressive weight gain and fatty tissue deposits, particularly around midsection and upper back, in the face (moon face) and between shoulders (buffalo hump), Striae on abdomen, thinning fragile skin that bruises easily, slow healing.

Fatigue, muscle weakness, hirsutism

Diagnostics

Treatments

Concerns

Occurs in women 3:1 Age 20-55

Check prolactin if galactorrhea or gynecomastia – big boobs or lactating = prolactin

Serum Prolactin ↑

↓ TSH, ↑ T3/T4 If Graves: + thyrotropin receptor antibodies (TRAb).

Thyroid peroxidase antibody (TPO) is positive in Graves and Hashimotos Thyroid Ultrasound

↑ TSH, ↓ free T4 (normal or low T3) ** subclinical hypothyroidism has elevated TSH and normal free T4 & T3

Refer to Endo for RAIU Start on beta-blocker (propranolol, nadolol) to counteract tachycardia and tremors Propylthiouracil (PTU) and Methimazole (Tapazole) shrinks gland/↓ hormone production (rash, anemia, thrombocytopenia, hepatic necrosis) radioactive iodine (ablation – then need levothyroxine) Supplement with Calcium and Vitamin D 1200mg plus weight-bearing exercise Use ideal body weight if pt. obese.

• Adults 1.6mcg/kg/day • Elderly (Start 25mcg) • Child 4mcg/kg/day • ↑ by 33% in pregnancy Check TSH about 8 weeks after tx

↑ incidence in women 7:1 ↑ risk for RA, pernicious anemia, osteoporosis Thyroid storm ↓ LOC, fever, abdominal pain

Levothyroxine should be taken with water on an empty stomach. Avoid taking within 2 hours of calcium, iron, aluminum, magnesium.

Report palpitations, nervousness, tremors

AM Cortisol level K+, Na+, ACTH Abdominal CT for adrenal glands, MRI pituitary gland

Corticosteroid replacement therapy Ample sodium during heavy exercise, hot climates and GI upsets.

During crisis, an immediate injection of hydrocortisone is needed along with support for low BP

Glucocorticoids (Cortisol) Mineralocorticoid (Aldosterone)

AM Cortisol level Syndrome caused by tumor Urine, blood and saliva can evaluate cortisol levels MRI or CT pituitary gland

Taper steroids as soon as possible; Can lead to heart failure or MI, osteoporosis, HTN, DM, frequent infections and loss of muscle ***Spironolactone– treat for hirsutism (can cause galactorrhea or gynecomastia)

↑ in school work so central obesity – very uncush…..

ENDOCRINE SYSTEM

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Diabetes Mellitus Type 1

Autoimmune disorder B-cell destruction results in abrupt cessation of insulin production

Unexplained weight loss despite eating a lot of food, ketonuria, polydipsia, polyphagia and polyuria, blurred vision, breath has “fruity odor” ketones in urine. Usually dx in the acutely ill child or younger adult (4-6 or 10-14) DKA – drowsiness, lethargy

A1c > 6.5% Fasting blood glucose >126 Random glucose >200 with polydipsia, polyphagia, polyuria and unexplained weight loss OGTT > 200

Check A1c q3months until well-controlled Lipid profile yearly Yearly urine for microalbuminuria ACEI or ARB for HTN (helps renal system)

Microvascular: retinopathy, nephropathy and neuropathy Macrovascular: atherosclerosis, CAD, MI

Insulin resistance with eventual insulin deficiency

Diabetes Mellitus Type 2

Risk factors: age > 45 overweight or obese, abdominal obesity, sedentary lifestyle, family hx 1st degree relative, HTN, HLD < 35, PCOS, hx vascular disease, metabolic syndrome, Hispanic, African American, Asian or American Indian

• Few if any symptoms, usually dx during routine screening; acanthosis nigricans (cutaneous manifestation of hyperinsulinemia) commonly seen on groin folds, over knuckles and elbows – will regress with weight loss and physical activity

•

Screening ADA: Annual for BMI > 25 and 1+ risk factor Everyone > 45 every 3 years if normal

A1c > 6.5% IFG > 126 Random glucose >200 with polydipsia, polyphagia, polyuria and unexplained weight loss OGTT > 200

Every visit: BP, feet, lifestyle - healthy eating, weight control, ↑ physical activity (150 min. week); <140/90 (ADA prefers <130/80) Yearly: flu shots, Aspirin 81mg daily, yearly eye exam/dental exam, thyroid, lipid profile, urine microalbuminuria Set A1c goal with patient.

A1c goal: <7% for most, 6% with low risk, <8% for elderly (varies with pt. attitude, risk for hypoglycemia, life expectancy, shorter duration with tighter control, comorbidities) Pre-prandial 80-130; Peak postprandial < 180; Bedtime 90-150 Start with Metformin (always prescribe with largest meal of day 500mg → 1000mg → 1500mg → 2000mg) Need ACEI multi drug combo such as: patient specificmetformin, sulfonylurea (improve fasting) add DPP4 (post meal insulin release)

Increased risk (diabetic in training) A1C 5.7-6.4% IFG 100-125 IGT= 140-199 ***A1c 2x year in those meeting goals and quarterly in those not meeting goals Meds that can ↑ risk of Type 2 DM – glucocorticoids, HCTZ, atypical antipsychotics, statins

Dual Therapy: Metformin Plus Sulfonylurea TZD DPP4 SGLT2 Efficacy High High Intermediate Intermediate Hypoglycemia Risk Moderate Low Low Low Weight Gain Gain Gain Neutral Loss Side Effects Hypoglycemia Edema, CHF, Fracture Rare GU, dehydration Cost Low Low High High Metformin unless contraindicated A1C > 9: Consider dual therapy initially A1C > 10-12: injectable insulin until less glucose toxic BG > 300: injectable insulin until less glucose toxic ***Meglitinides for irregular eating schedule DC sulfonylureas, glitazone after initiating insulin (SU plus insulin is less efficacious with more weight gain)

GLP – 1 High Low Loss GI High

GASTROINTESTINAL SYSTEM

CONSTIPATION ➢ Idiopathic and functional ➢ Lifestyle factors o Immobility o Low-fiber diet o Dehydration o Milk intake o Ignoring the urge to have BM ➢ Drugs contributing to constipation o Iron supplements o Beta-blockers o Calcium channel blockers o Antihistamines o Anticholinergics o Antipsychotics o Opiates o Calcium-containing antacids ➢ Treatment o Bowel retraining o Dietary changes o Ingest bulk forming fiber (25-35 g/day) o Increase physical activity o Increase fluid intake (8-10 glasses) o Consider laxatives

ANAL FISSURE ➢ Ulcer or tear of anus, most often posteriorly ➢ Severe anal pain (razor blades) with bowel movements lasting hours after the BM – pain leads to constipation and drops of blood when wiping ➢ Risk factors include constipation, diarrhea, childbirth, anal sex ➢ Primary treatment is to prevent constipation - ↑ dietary fiber, laxative (mineral oil – avoid long term use due to inability to absorb A, D, E, K vitamins), sitz bath, cool compresses. If these measures fail NTG, Botox, surgical sphincterotomy

HEMORRHOIDS ➢

➢

Grade I – no prolapse, Grade II – prolapse upon defecation but reduce spontaneously, Grade III – hemorrhoids prolapse upon defecation and must be reduced manually, Grade IV – hemorrhoids are prolapsed and cannot be reduced manually. ↑ risk excessive alcohol, chronic diarrhea or constipation, obesity, high fat, low fiber diet, prolonged sitting, sedentary lifestyle, anal intercourse and loss of pelvic floor muscle tone.

HEPATITIS SEROLOGY ➢ IgG – produce after the infection is Gone o Antibodies present (immune) ▪ No virus / not infected ➢ IgM – antibody you make the Minute you get infected o Acute infection – contagious ▪ No immunity ➢ Hepatitis A o Fecal-contaminated food/water o Anti-HAV IgG – positive ▪ Immune to HAV o Anti-HAV IgM – positive ▪ Acute infection o Anti-HAV IgM and IgG negative – no immunity, needs immunization ➢ Hepatitis B o HBsAg – (surface antigen) screening for Hep B ▪ Positive – has virus on board o Anti-HBs (surface antibody)– positive ▪ Antibodies present / immune o Anti-HBc (totally Hep B core antibody) ***rotten to the core*** o IGM anti-HBc ➢ Hepatitis C o Injection drug use o Anti-HCV – screening for Hep C (? Exposure – if negative order HCV RNA) ▪ If positive – order HCV RNA or PCR to r/o chronic infection • If positive RNA/PCR has Hep. C – refer o Screen those born from 1945-1965 ➢ Hepatitis D o Requires presence of Hep. B. Can be acute/chronic o Infection of B/D increases risk for cirrhosis and liver damage ➢

GASTROINTESTINAL SYSTEM

ABDOMINAL MANEUVERS (POSITIVE IN APPENDICITIS) ➢ Psoas/Iliopsoas (supine) – Flex hip 90° have pt. push against resistance and to straighten leg

➢ Obturator sign (supine) – Internal rotate right hip full ROM. + pain with movement/flexion of the hip

➢ Rosving’s sign – Deep palpation of LLQ = pain RLQ

RANDOM INFO

ABDOMINAL MANEUVERS ➢ Markle Test (heel jar) – o Raise heels then drop suddenly or jump.

Positive if pain is elicited or pt. refuses due to pain. ➢ Involuntary Guarding o Abd. Muscles reflexively become tense when palpated ➢ Rebound tenderness/Blumberg o Abdominal pain worse when palpating hand releases suddenly ➢ Murphy’s maneuver – Press deeply RUQ under costal border during inspiration. Mid-inspiratory arrest + finding ➢ Cullen’s sign – edema and blue discoloration around umbilicus ➢ Grey Turner’s sign – blue discoloration on flanks that may indicate retroperitoneal hemorrhage

➢ Prolonged PPI Usage o Vitamin B12, calcium, magnesium, iron malabsorption, possible ↑ fx and C. diff risk ➢ Partial obstruction plus chronic low volume bleeding o Esophageal Stricture o Esophagitis o Esophageal Cancer ▪ Needs endoscopy ➢ Bowel obstruction – abdominal pain associated with dilated loop of bowel and tinkling bowel sounds. KUB – ileus.

Refer ➢ Ileus – absent bowel sounds – KUB ➢ Gilbert’s Disease - ↑ Bilirubin only ➢ Acute abdominal pain LUQ for 60 minutes - EKG

LFT’S

➢ McBurney’s point – Area between superior iliac crest and umbilicus in RLQ

➢ Aspartate Aminotransferase – (AST) (SGOT) present in liver, heart, muscle, kidney and lung ➢ 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) ➢ AST/ALT Ratio o 2.0+ = alcohol abuse o 1-2 = ETOH, liver disease o <1 = fatty liver disease ➢ Serum GGT – elevated in liver abuse and acute pancreatitis; sensitive for alcohol abuse ➢ 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 ➢ Albumin – liver makes albumin ➢

GASTROINTESTINAL SYSTEM

Name

Cause

Signs/Symptoms

Diagnostics

Acute Appendicitis

Inflammatory disease caused by infection or obstruction

Acute Cholecystitis

Inflammation of gallbladder nearly always caused by gallstones

Acute Diverticulitis

Infected diverticula (diverticulosis most common in sigmoid colon)

Acute onset periumbilical pain steadily worsening over 12-24h. Pain localizes at McBurney’s point with rebound and guarding, anorexia. Psoas and obturator signs + If ruptures, have guarding, rebound, and board like abdomen.

Severe RUQ or epigastric pain constant with 23 minutes of increased pain (colicky pain) can occur w/in 1h of consuming fatty meals. Pain can radiate to right shoulder, N/V, anorexia, intermittent fever, + Murphy’s sign

CT with contrast **Abd US can be used in younger thinner people Left shift: ↑ WBC, ↑ neutrophils, ↑ Bands

REFER

Elevated AST, ALT and ALP RUQ abdominal US - HIDA

Gut rest with clear liquids REFER to Surgery

Fever, anorexia, nausea, cramping, LLQ pain.

- Blumberg’s sign; Acute abdomen rebound, Rovsing +, board like abdomen.

Diverticulosis – exam normal 33% of population will develop diverticulosis by age 50

CBC shows leukocytosis w/ neutrophilia Bands signal severe bacterial infection; FOBT + if bleeding CT scan definitive scan

Ciprofloxacin + Metronidazole 10-14d or Levaquin + Flagyl High fiber diet Follow-up in 48-72h If worsens refer to ER

Acute onset fever, N/V associated with rapid onset severe abdominal pain radiating to mid-back with bloating. Guarding and tenderness over epigastric region on exam. + Cullen’s sign and Grey-Turner’s sign **rocks back and forth to relieve pain

↑ serum amylase, lipase and trypsin; ↑ AST and ALT, GGT, bilirubin, leukocytosis; abdominal ultrasound and CT Triglycerides > 800 ↑ risk

Drug use, Alcohol abuse, gallstones, elevated triglycerides, infections

REFER

Clostridium difficile Colitis (C-diff)

Severe watery diarrhea 10-15 stools a day w/ lower abdominal pain, cramping and fever.

Symptoms appear 5-10d after antibiotic initiation (clindamycin, quinolones, cephalosporins and PCNs)

CBC w/ leukocytosis (>15,000) Stool assay for C-diff

Metronidazole (Flagyl), avoid antimotility agents and opiates, increase fluid intake

Colon Cancer

adenocarcinomas 3rd leading cause of cancer deaths in US

Asymptomatic until advanced disease. Vague GI symptoms, changes in bowel habits, stool or bloody stool. Heme-positive stool, dark tarry stool, mass on abdominal palpation. May have hx of polyps

Colonoscopy age 50 (repeat every 10 yrs. unless polyps) <40 assess cancer risk; FOBT annually ever year; Cologuard every 3 yrs.

Screen everyone with these questions: Have you ever had colorectal cancer (CRC) or adenomatous polyp (AP)?

Inflammatory bowel disease? Family member with CRC or AP? If CRC - Surgery, chemo and radiation

↑ risk factors >50 yrs.; multiple polyps or inflammatory bowel disease (diet in high fat, red meat and low calcium may contribute

Crohn’s Disease

Inflammatory bowel disease affecting mouth to anus (Inflammation affects entire intestine wall)

Lactulose intolerance is common. Stop smoking. Gut rest. Oral aminosalicylates sulfasalazine and mesalamine (better tolerated). Flagyl and Cipro. Immune modulators

↑ risk of toxic megacolon and colon cancer; risk of development of lymphoma especially when treated with azathioprine. More common in Jews

Ulcerative Colitis

Inflammatory disease affecting colon/rectum (Inflammation affects mucosa)

Oral aminosalicylates sulfasalazine and mesalamine (better tolerated) Corticosteroids. No antibiotics due to risk of C. Diff. Immune modulators

↑ risk of toxic megacolon and colon cancer

Acute Pancreatitis

fever, malaise and mild weight loss, periumbilical to RLQ pain. May palpate tender abdominal mass. Remission and relapses are common. If ileum involved, diarrhea without blood or mucous. If colon involved bloody diarrhea with mucus. Fistula formation and anal disease. bloody diarrhea with mucus. Severe “squeezing” cramping pain located on left side of abdomen with bloating and gas exacerbated by food. Relapses characterized by fever, anorexia, weight loss and fatigue. Accompanied by arthralgias and arthritis that affects large joints, sacrum and ankylosing spondylitis. May have IDA or anemia of chronic disease

↑ CRP, ESR, Leukocytosis Anemia (chronic disease, B12 deficiency) WBCs in stool Cobblestone mucosal pattern on endoscopy – skin lesions

↑ CRP, ESR, Leukocytosis Anemia WBCs in stool

Treatments

Concerns

Peak age 10-30 myelocytes/metamyelocytes (immature neutrophils) – ominous marker in lifethreatening infection found in appendiceal rupture Risk factors: fair, fat, 40 Cholelithiasis – stones, no inflammation Collins – pain radiating to right shoulder Risk factors: ↑ age, constipation, low dietary fiber intake, obesity, lack of exercise, NSAIDs, family hx, connective tissue disorder, Complications: Sepsis, Ileus, SBO, hemorrhage, perforation, fistula, death Ileus, sepsis, shock, multiorgan failure **Risk factors for pancreatic CA include chronic pancreatitis, tobacco use, DM

GASTROINTESTINAL SYSTEM

Name

Cause

Signs/Symptoms

Diagnostics

Zollinger-Ellison Syndrome

Gastrinoma on pancreas or stomach

Gastrin secretion stimulating high acid production of stomach. Develops ulcers in stomach and duodenum. Epigastric to midabdominal pain; stools may be tarry colored

Fasting gastrin levels

Treatments

Concerns

Chronic GERD may result in Barrett’s esophagus ↑ risk of squamous cell cancer – (followed by GI – lifetime PPI with endoscopic biopsy annually – 6 months)

Gastric contents regurgitate from stomach to esophagus due to reduction in LES tone, irritation of esophageal mucosa, ↑ gastric secretion

Chronic heartburn over time with large/fatty meals worsening when supine. Recurrent dry cough, chronic pharyngitis, and hoarseness.

Self-tx w/ OTC antacids and H2 blockers. May be due to chronic NSAID use, aspirin, or alcohol ***Anyone with GERD x 10 yrs. should be referred to GI to R/O Barrett’s

HPI – Clinical Dx Endoscopy when dysphagia, odynophagia, unintended weight loss, hematemesis, melena, chest pain or choking

First line treatment is lifestyle changes (avoid eating 3-4 hours before bedtime, dietary changes and weight loss) avoid triggers (mints, chocolate, alcohol, ASA, NSAIDs, caffeine, carbonated beverages) Stop smoking. Evaluate meds: BB, CCB, alpha agonist, estrogen, progesterone.

2nd line: Can combine lifestyle changes with antacids or H2 blockers (prn up to 12 hours), if no relief: PPI once a day, before the 1st meal of day (long term therapy associated with hip fx, pneumonia, C Diff.; wean off due to rebound) – If no relief after 4-8 weeks, refer to GI

Irritable Bowel Syndrome (IBS)

Disorder of colon (spastic colon)

Intermittent episodes of moderate to severe cramping in lower abdomen, especially LLQ. Bloating with flatulence. Relief after defecation.

Stools range from diarrhea to constipation.

Exacerbations/remissions. Commonly exacerbated by stress.

Abdominal exam tenderness in lower quadrants R/O bacterial infections ROME III criteria: recurrent discomfort 3 days/month in last 3 months with 2+ Discomfort relieved by defecation, change in stool form or appearance

Increase fiber, avoid gas producing foods: beans, onions, cabbage, highfructose corn syrup. Antispasmodics. If constipation based – trial fiber supplements, Miralax. If diarrhea-based take Imodium before regularly scheduled meals. Decrease life stress

Erosive Gastritis (Gastric Ulcer)

H. pylori; Too much stress, alcohol or NSAIDs

Intermittent epigastric pain, burning/gnawing pain. Pain worse with eating, tender at epigastrium

Worrisome symptoms: dysphagia, early satiety and weight loss

H. pylori

Episodic epigastric pain, burning/gnawing pain.

Pain relieved by food or antacids with recurrent 2-3 hours after meals. Awakens at 1-2am with symptoms

H. pylori stool antigen test or urea breath test (no serological H. pylori because will test positive if ever infected)

GERD

Duodenal Ulcer

Viral Hepatitis

A: Fecal/oral B: sexual; mother to child; blood transfusion C: IV drug abuse, blood transfusion

fatigue, nausea, anorexia, malaise, abdominal pain, dark colored urine, clay stools and joint pain for several days. Skin and sclera have a yellow tinge. Tenderness over liver with percussion and deep palpation. ↑ ALT/AST up to 10x normal. Remove and treat cause. Avoid hepatotoxic agents such as Tylenol, alcohol and statins. Treatment is supportive Periodic monitoring for alpha-fetoprotein to look for hepatoma (hepatocellular carcinoma) May have aversion to smoking

H. pylori negative: Stop NSAIDs, (if needs NSAIDs add PPI or misopristol).

Stop alcohol. Stop smoking. Stress management. Lifestyle changes with H2 blockers the step up to PPI. H. pylori positive: triple therapy Clarithromycin + Amoxicillin + omeprazole (Flagyl if allergic to Amoxicillin) x 14 d

***CCB – blocks calcium and ↓ electoral conductivity – smooth muscle relaxer which ↓ LES and increases GERD

More commonly affects females

Sudden abruption of medication can cause rebound worsening symptoms More common H. pylori is transmitted oral/fecal and oral/oral

Reportable to public health department Hep A: Asymptomatic; Hep A symptoms start about 28 days after exposure; Post-exposure and not vaccinated (age 1-40, give HAV) if >40 give IG within 2 weeks of exposure; avoid oral contraceptives to avoid cholestasis; avoid alcohol. Avoid working in food-related jobs for 1 week after onset of infection Hep B: acute, self-limiting or chronic infection. Tx: first-line agents pegylated interferon alfa (PEGIFN-a), entecavir (ETV), and tenofovir disoproxil fumarate (TDF) – Offer vaccine to those born before 1986 - cannot get vaccine if anaphylaxis to baker’s yeast. Post-exposure and vaccinated give HBV, if in the process of vaccination series, give HBIG and complete series. Unvaccinated should receive HBIG and start vaccine series within 24 hours of exposure if possible Hep C: approximately 75-85% of people who will become infected will develop chronic infection.

Most common cause of liver cancer and liver transplantation. Screen adults from 1945-1965 Tx: administer antivirals such as ledipasvir-sofosbuvir (Harvoni), ribavirin, and pegylated interferon alpha 2a/2b

NERVOUS SYSTEM

CEREBELLAR SYSTEM ➢ Romberg Test – stand with arms/hands straight on each side and with feet together. Have eyes closed; Positive if excessive swaying or imbalance (Proprioception) ➢ Tandem test – have pt. walk straight line in normal gait. Instruct to walk in straight line with one foot in front of the other. Positive if loose balance, falling, or unable to walk straight

NEUROLOGICAL MANEUVERS ➢ Kernig’s sign – flex pt. hips one at a time, attempt to straighten leg while keeping hip flexed at 90° ➢ Brudzinski’s sign – passively flex/bend patient’s neck toward chest. Positive if patient flexes hip and knee to relive pressure and pain ➢ Nuchal rigidity – tell patient to touch chest with chin. Inability to touch chest secondary to pain is positive.

CEREBELLAR TESTING

CRANIAL NERVES

Coordination (Diadochokinesia) ➢ Rapid alternative movement: patient to place lower arms on top of each thigh and move them alternating between supination and pronation positions ➢ Heel-to-shin testing: patient in supine position with extended legs. Patient to place the left heel on the right knee and then move it down the shin – repeat w/ right heel on left leg Sensory ➢ Vibration, Sharp-dull touch, temperature Stereognosis – recognizes familiar object w/ sense of touch Graphesthesia – identify figures “written” on skin Motor ➢ Gait – observe normal gait; check leg muscles for atrophy ➢ Pronator drift test – stretch out arms w/ palms facing up, eyes closed. Observe for 5-10 seconds for drifting of arms. ➢ Reflexes – o Quads (Knee-jerk) o Achilles (ankle-jerk) o Plantar (Babinski)

** Some Say Marry Money But My Brother Says Big Brains Matter More (Sensory, Motor, Both) I (S) – Olfactory smell (one nose) II (S) – Optic visual acuity, visual field, fundoscopy (2 eyes) III (M) – Oculomotor upward/medial/downward movements of eye (need CN 3 to look up) IV (M) – Trochlear eyes down and in V (B) – Trigeminal touch forehead and cheeks clench teeth VI (M) – Abducens eyes look side to side VII (B) – Facial crease forehead, close eyes tight, puff out cheeks and smile real big VIII (S)– Vestibulocochlear/Acoustic, hearing, equilibrium (2 ears sitting on top of each other, Rinne and Weber) IX (B) – Glossopharyngeal speech (gag reflex) X (B) – Vagus digestion, defecation, slowed heart rate (need CN10 to stick out tongue) XI (M) – Accessory Spinal shoulder shrug XII (M) – Hypoglossal stick out their tongue

CRANIAL NERVE TRICKS ➢ Cranial nerves responsible for extraocular eye movements? o 3, 4, 6 – make the eyes do tricks

3 MINUTE NEURO EXAM: -

Stand with eyes closed: Romberg With eyes open: Tandem gait Walk on tip toes (power test of plantar flexion) Walk on heels (power test of dorsiflexion) With eyes closed Pronator Drift followed by finger to nose test With eyes open: play the piano (pyramidal function) Rapid taping or alternative movements Close eyes tightly (CN VII) Open eyes – observe pupillary reflex (CN II, III) Smile (CN VII) Stick out tongue (CN XII) Rapid tongue movements (pseudobulbar palsy) Visual fields by confrontation (CN II) Eye movements (CN III, IV & VI) Babinski Fundoscopy

NERVOUS SYSTEM

MIGRAINES Headache Migraine without aura

Migraine with aura

Trigeminal neuralgia (CN V)

Cluster

Temporal arteritis (giant cell arteritis)

Muscle tension

Symptoms Throbbing pain behind one eye, photophobia, N/V phonophobia, last 4-72 hr.

Preceding symptoms plus scotoma, lights, halos, last 4-72 hr.

Intense and very brief, sharp stabbing pain, one cheek Severe “ice-pick” piercing pain behind one eye and temple; with tearing, rhinorrhea, ptosis and miosis on one side (Horner’s syndrome) Unilateral pain, temporal area with scalp tenderness, skin over artery is indurated, tender, warm and reddened; amaurosis fugax (temporary blindness) Bilateral “band-like” pain, continuous dull pain, may last all day; may be accompanied by spasm of trapezius muscle

Aggravating Factors Red wine, MSG, aspartame, menstruation, stress Foods high in triptans.

Teenage to middle-age females Cold food, cold air, talking, touch, chewing, older adults and elderly Occurs at same time daily in clusters for week to months; middle aged males

Acute Treatment Ice pack on forehead, rest in dark quiet room Triptans, Tigan suppositories

Prophylaxis TCAs Episodic migraine (<14 days per month) Beta-blockers

Carbamazepine (Tegretol) or phenytoin (Dilantin) Check serum levels 100% oxygen at 12 LPM Intranasal 4% lidocaine

Tegretol or Dilantin Watch for drug interactions May become suicidal Spontaneous resolution ETOH can trigger

Medical urgency; polymyalgia rheumatica (up to 50%); older adults and elderly

Refer to ED or ophthalmologist Lab: ESR High dose steroids

Permanent blindness; temporal artery biopsy is gold standard

Stress Adults

NSAIDs, Tylenol, hot bath/shower, massage, etc.

Stress reduction, yoga, massage, biofeedback

HEADACHE TREATMENT COMMON DRUGS: ➢ ACUTE TREATMENT: ➢ NSAIDs – GI pain/bleeding/ulceration, renal damage, ↑ BP in HTN ➢ Triptans – Nausea/Acute MI; use with caution in cardiovascular co-morbidities, not within 24 hours of ergot; not within 14 days of MAOI ➢ Analgesics – Tylenol; hepatic damage, prophylaxis – must be taken daily to work ➢ PROPHYLAXIS: ➢ Tricyclic Antidepressants – Elavil or imipramine at ½ strength; sedation, dry mouth, confusion in elderly ➢ Beta-blockers – propranolol or atenolol daily; contraindicated in 2 nd or 3rd degree heart block, asthma, COPD, bradycardia ➢ Antiseizure medications – Topamax – requires titration; should not be prescribed in a hx of kidney stones

CONCUSSION ➢ Headache, loss of memory, confusion, dizziness, ringing in ears, N/V ➢ Must pass protocol to return to play ➢ Risk for subdural hematoma if hit head

NERVOUS SYSTEM

HEADACHES PRIMARY Not associated with any other diseases Migraine, tension-type, cluster

**more common

SECONDARY Associated with or caused by other conditions Tumor, intracranial bleeding, ↑ICP, meds like NTG, meningitis, giant cell arteritis

Red Flag Headaches: Systemic symptoms: - Fever, unintended weight loss - Secondary HA Risk factors: HIV, malignancy, pregnancy, anticoagulation, HTN Neurological signs, symptoms: - Newly acquired symptoms, confusion, impaired alertness or consciousness, nuchal rigidity, HTN, papilledema, CN dysfunction o Acceptable abnormalities include Photophobia & phonophobia - Unequal pupil size Onset: sudden, abrupt or split-second “thunderclap” headache (subarachnoid) onset with exertion, sex, cough ↑ICP Older >50 or < 5 years Previous headache history - Less worrisome if have had HA before - “worst headache of my life” – r/o subarachnoid Rule-Out: - Subarachnoid or acute subdural - Leaking aneurysm - Bacterial meningitis - Increased ICP - Brain abscess or tumor

BRAIN DAMAGE: ➢ Apraxia: difficulty performing purposeful movements ➢ Broca’s aphasia: “nonfluent aphasia” Pt comprehends speech and can read, but has difficulty with motor aspect of speech – word salad ➢ Wernicke’s aphasia: “fluent aphasia” Pt has difficulty with comprehension but has no problem with speaking. Reading and writing can be impaired. ➢ Frontal lobe damage: (intelligence, personality) dementia, memory loss, difficulty to learn

MINI-MENTAL STATE EXAM (MMSE):

HEADACHE EVALUATION: ➢ History o Where does it hurt? o Characteristics? o Patient appearance (lights out, fetal position vs reading iPad) o Duration o Associated symptoms ➢ Exam – physical including fundoscopic and neuro exam o BP, pulse o Palpate head, neck, shoulders, spine o Bruits ➢ If you are 35+ and develop a new headache – you bought an expensive test ➢ If ordering imaging notes should reflect: o Red flag headache o Change in pattern, frequency or severity of HA o Worsening of HA despite therapy o Unexplained neuro symptoms o Headache always on the same side o Onset of HA with exertion, cough, intercourse o New onset > 50 yrs. o HA associated with fever, stiff neck, papilledema, cognitive impairment or personality change

MINI COG: ➢ ➢ ➢ ➢ ➢

Three-word recognition Clock drawing (normal or abnormal) Three-word recall Dementia if score 0-2. No dementia if >3

-

-

Orientation Short term memory - Recite 3 unrelated words Attention and calculation Spell “world” backwards or subtract 7 starting at 100 Recall – ask to repeat the words Write sentence Copy design While speaking, look for aphasia (impairment in language resulting in difficulty speaking)

HEADACHE DIFFERENTIAL: -

-

Nasal stuffiness: sinusitis Jaw claudication, fever, visual loss, pain in temple: temporal arteritis*** Visual field defect: Optic pathway lesion (pituitary tumor) Blurred vision on bending head: intracranial lesion Headache with N/V: tumor Unilateral vision loss: optic neuritis Sweating, tachycardia: pheochromocytoma Transient visual changes: pseudotumor cerebrii***

NERVOUS SYSTEM

Name

Signs/Symptoms

Diagnostics

Strep pneumonia Neisseria meningitides Haemophilus influenza

High fever, severe headache, stiff neck and meningmus. Rapid changes in mental status.

Purple-colored petechial rash w/ N/V and photophobia. Worsening symptoms to lethargy, confusion and coma

Lumbar puncture: CSF large WBC, ↑ protein, ↓ glucose CT/MRI CBC, CMP, Coags, Blood culture x 2 Gram stain and C&S of CSF

Temporal arteritis (Giant cell arteritis)

Autoimmune vasculitis of temporal artery

Acute onset headache located on one temple, usually in older adult; induration, redness, cordlike temporal artery accompanied w/ scalp tenderness. Abrupt visual changes and/or transient blindness (amaurosis fugax). Some people may also complain of jaw pain.

Stroke (CVA)

Embolic or hemorrhagic

Embolic: Acute onset stuttering/speech changes, one-sided facial weakness, hemiparesis Hemorrhagic: May have poorly controlled HTN and severe headache, N/V, and nuchal rigidity

Chronic subdural hematoma (SDH)

bleed between dura and subarachnoid membrane

History of head trauma and HA with gradual cognitive impairment (apathy, somnolence, confusion) More common in elderly & those on anticoagulation or ASA therapy

Head trauma

Sudden onset HA “worst HA ever” w/ photophobia, N/V, meningeal irritation (+Brudzinski and Kernig signs), decline in LOC. Elderly – fall Younger – MVC

Acute bacterial meningitis

Subarachnoid hemorrhage (SAH)

Cause

Elevated ESR Elevated CRP

Treatments

Report to Health Department.

Infants: Ampicillin or 3rd gen. cephalosporin Adults: 3rd gen. cephalosporin + Chloramphenicol >50: amoxicillin + 3rd gen. cephalosporin Prophylaxis of close contacts with rifampin or ceftriaxone

Migraine (with or w/o aura)

***Note motion sickness and migraines come from same gene

Fatal if not treated

Refer to ophthalmologist or ED Biopsy is definitive test High-dose steroids 40-60mg daily (Add PPI to prevent ulcer and possibly bisphosphonate for bone health)

Mean age dx 72 Permanent blindness ***women more likely than men Pt’s with polymyalgia rheumatica are at very high risk 30%

911 – Assess ABCs Risk factors – A fib and HTN; aneurysm, anticoagulants, stimulants, sickle cell, diabetes, oral contraception, smoking.

Blacks, Hispanics and Indians have ↑ prevalence

Sentinel headache – can occur a few up to 20 days before event.

Migraine without aura HA last 4-72 hrs.; has 2 characteristics (unilateral pulsating quality, mod to severe intensity, aggravated by routine activity) • has one of the following (Nausea and/or Vomiting, photophobia or phonophobia) • 5 or more attacks • no other reason for HA Migraine with aura • 2 attacks with aura • Visual, sensory, motor reversible • Develops over 5-20 min; HA w/in 60 min.

• •

Gradual onset throbbing headache behind one eye gradually worsening over several hours; photophobia and phonophobia. May last 2-3 days and become bilateral if not treated Aura can be paresthesia, seeing halos, metallic taste, hyperosmia, Scotomas (blind spots in visual field) etc.

Positive family history and being female increases risk factors. In children, migraines can present as abdominal pain.

Concerns

Rest in dark room w/ ice; avoid triggers (MSG, chocolate, ripened cheese, fermented foods, alcohol, caffeine, sleep changes, stress, menses, skipping meals, odors, bright light, change in weather) Abortive tx: triptans, NSAIDs, antiemetics Prophylactic tx: beta-blockers, TCAs, anticonvulsants (avoid if hx of kidney stones) (Butterbur, feverfew and magnesium)

Contraindications for triptans: ischemic heart disease, CVA, TIA, HTN, diabetes, obese, male > 40, HLD; ↑ risk of serotonin syndrome with SSRI or SNRI; Do not start within 2 weeks of MAOI use; Do not combine with ergots ***Avoid use of combined estrogen-progestin oral contraceptive in migraine with aura due to stroke risk

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Basilar or hemiplegic migraine

Focal neurological finding with stroke-like s/s. resembles TIA.

Polymyalgia Rheumatica (PMR)

Bilateral morning stiffness and aching of shoulders, neck, hips, and torso (difficulty putting on bra)

↑ ESR ↑ CRP

Symptoms usually respond quick to oral steroids

High risk of developing temporal arteritis More common > 50

Trigeminal Neuralgia (Tic Douloureux)

Compression of CN V root by artery or tumor

Unilateral facial pain following one of the branches of the trigeminal nerve. Pain usually located close to the nasal border and the cheeks triggered by chewing, eating cold foods or cold air lasting few seconds Type I: extreme, shock-like facial pain lasting 2 minutes to 2 hours Type II: constant, aching, burning facial pain of lower intensity

MRI/CT to r/o tumor/artery pressing on nerve or Multiple Sclerosis

High doses anticonvulsants carbamazepine (Tegretol) or phenytoin (Dilantin); muscle relaxants, gabapentin

More common in women and peaks in 60’s

Bell’s Palsy

Dysfunction of CN VII Viral infection, autoimmune or pressure from tumor/blood vessel

Facial paralysis progressing rapidly within 24h, difficulty chewing and swallowing food on same side, unable to fully close eyelids and tear production may stop

High dose corticosteroids x 10 days (wean) Acyclovir (Zovirax) if herpes suspected Protect cornea from drying and ulceration w/ lubricant. Patch eye at night to close with eyelid.

Corneal ulceration, permanent neurological sequelae or facial weakness if prolonged case

High dose oxygen (100% 12LPM for 15 minutes), sumatriptan (Imitrex) May take verapamil for prophylaxis

High risk for suicide More men > women

NSAIDs, OTC analgesics + caffeine (Excedrin), stress reduction and avoid triggers

Narcotics and butalbital are habit forming and ↑ rebound headaches

Cluster headache

Idiopathic

Tension headaches

Emotional/psychic stress

Rebound headache

Overuse of abortive medicines, NSAIDS, aspirin, narcotics

Transient Ischemic Attack (TIA)

Carpal Tunnel Syndrome (CTS)

Avoid estrogen agents

HPI - R/O CVA, TIA, mastoid infection, bone fx, Lyme disease and tumor

Abrupt one-sided headache marked by recurrent episodes of brief “ice-pick” pain behind one eye w/ tearing and clear rhinitis. May have Ptosis Happens several times a day, may resolve spontaneously Headache that is “bandlike” or “squeezing”, dull and constant; may follow tensing of neck muscles and last several days Prevention: yoga, tai chi, exercise, regular eating/sleep schedule, counseling Daily headaches w/ irritability, depression and insomnia

Discontinue medicines or gradually taper off

Focal ischemia – brain, spinal cord, retinal ischemia

Abrupt onset difficulty speaking, unilateral hemiparesis, dizziness, vertigo, weakness and poor balance. Slurred speech (aphasia). The longer the episode, the higher the risk of damage.

CT/MRI within 24 hrs. of episode

Refer to ED - Consider hospitalization within 24-48 hrs.: Patient’s first TIA – or TIA > 1 hour; ↑ risk cardiac emboli – A fib; Symptomatic internal carotid stenosis >50%; hypercoagulable state; crescendo TIA; High ABCD2 score

Up to 20% will have stroke within 90 days

median nerve compression

Gradual onset of numbness and tingling on thumb, index finger and middle finger affecting hand grip. Acroparethesia – awakening at night with numbness and burning pain in fingers.

Problems lifting objects w/ affected hand. Hx occupation or hobby involving frequent wrist movement

Tinel’s sign – tap anterior wrist briskly. + if “pins and needles” sensation Phalen’s sign – full flexion of wrist for 60 sec. + if tingling of median nerve EMG and nerve conduction

Primary prevention – limit time spent with activities, ensure proper breaks and encourage toning and stretching exercises Elevation, application of volar splint in neutral position SLE

Factors that ↑ risk are repetitive motion, hypothyroidism, pregnancy and obesity

NERVOUS SYSTEM

Name

Vertigo

Cause

Signs/Symptoms

NOT DIAGNOSIS

Symptom of vestibular dysfunction, Spinning, swaying, tilting, N&V, postural instability. Single episode or recurrent Peripheral etiology: involves the vestibular system; severe N/V, recurrent < 1 minute Central etiology: involves the brainstem or cerebellum – prolonged nystagmus, impaired gait/mobility, single episode lasting minutes to hours

Diagnostics

Treatments

If you can get the patient to focus on an object and get the vertigo to stop, without shifting gaze – you can keep them. Otherwise refer

Benign Paroxysmal Positional Vertigo: brief, recurrent, symptoms are reproducible, attributed to calcium debris in semicircular canals; Dix-Hallpike maneuver; change in position precipitates symptoms Tx with antihistamines like meclizine & Dramamine or Benzos like alprazolam or lorazepam and TIME

Symmetrical, burning, weakness and sensory loss, variable course, rapid progression, lower extremity more common with symptoms distal to the trunk

Polyneuropathy

Concerns

Risk factors: diabetes and alcohol abuse

Parkinson’s – chronic progressive; average age of 70; tremor at rest, pill rolling tremor, bradykinesia and rigidity.

• Levodopa first line treatment – refer Tremors

Multiple Sclerosis

Essential Tremor – most common; familial (50% autosomal dominant trait); more common with aging, bilateral action tremor of hands, forearms, head, voice, chin and lip tremor – tremor in legs in unusual.

• Betablocker Immune mediated, inflammatory, demyelinating disease of CNS

Dementia

Decline in cognition

Delirium

Prescription meds, substance abuse, drugdrug interaction, abrupt drug withdrawal, preexisting medical condition, infections, electrolyte imbalance, heart failure, renal failure

Young adult with abnormal limb sensation, visual loss, motor symptoms, diplopia, gait disturbance, acute motor symptoms

Insidious; decline in complex attention, executive function, learning memory, perceptual motor, social cognition.

Cognitive deficits must be severe enough to interfere with function and independence

Reversible, temporary process. Duration is usually brief (hours to days). Pt may be excitable, irritable, combative, short attention span, memory loss and disorientation.

MRI

Refer to neurology

Normal or abnormal cognition?

Dementia, delirium or depression?

MMSE: <24 suggestive dementia Medications that impair cognition: analgesic, anticholinergic, psychotropic, sedative-hypnotics CBC, CMP, B12, folate, TSH, UA, RPR, HIV, CT and/or MRI Screen for depression

Declining cognitive function need safety assessments: • Driving • Financial capacity • Wandering • Living alone Caregiver burnout, polypharmacy, family conflict over decision making, risk of injury, elder abuse

Most common cause is Alzheimer disease followed by Lewy bodies.

Remove and or treat illness, infection or metabolic derangement

Sundowning – occurs in delirium and dementia.

Starting at dusk, the patient becomes agitated, confused and combative and symptoms resolve in the morning. Avoid dark, quiet spaces. Use radio, do not move furniture or décor.

HEMATOLOGICAL SYSTEM

HOW BLOOD CELLS MADE ➢ ➢

RBC, WBC, Platelets come from Stem cell Infection o Bacterial or allergic ▪ Neutrophil - infection ▪ Eosinophil – allergic reaction ▪ Basophil - anaphylaxis o Viral ▪ Lymphocyte o Tissue damage ▪ Monocyte

➢ When poly/lymph close = viral ➢ When poly/lymph far = bacterial ➢ Pt should look like labs.

HEMOGRAM EVALUATION IN ANEMIA ➢

➢

HOW BLOOD CELLS MADE ANEMIA ➢ RBC, WBC,ofPlatelets from Stem cell Complex signs andcome symptoms ➢ Infection o ↓RBC, ↓ hemoglobin, ↓hematocrit o blood Bacterial or allergic in primary care) ➢ Acute loss (uncommon ➢ Chronic blood▪ lossNeutrophil (common -ininfection primary care) ▪ gastritis, Eosinophil – allergic reaction o Erosive menorrhagia, GI malignancy ▪ to Basophil - anaphylaxis o Leads IDA o Viral ➢ Reduced RBC production (sick bone marrow) ▪ B12, Lymphocyte o Vitamin folic acid, iron deficiency, anemia o Tissue damage of chronic disease, bone marrow suppression, ▪ Monocyte reduced erythropoietin production (chronic renal failure) – select medications (PPI, metformin) ➢ Premature destruction (uncommon) o Shortened RBC lifespan (90-120 days normal) o Sickle cell anemia, thalassemia, hemolytic G6PD deficiency ➢ In a person with normal bone marrow production, supplementing the deficient substance will cause H/H to increase in 1-2 weeks and normalize within 4-8 weeks

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What are hematocrit, hemoglobin, and RBC values? o Normally hemoglobin to hematocrit ratio 1:3 ▪ 10 = 30% ▪ 12 = 36% ▪ 15 = 45% o Severe dehydration causes elevated hematocrit o Testosterone = more RBC (hence male have higher hematocrit values) What is the RBC size? o RBC size is same size during life o MCV (cytic = size) ▪ Microcytic <80 ▪ Normocytic 80-96 ▪ Macrocytic > 96 o In evolving microcytic anemia ▪ As MCV ↓ RDW ↑ o In evolving macrocytic anemia ▪ As MCV ↑ RDW ↑ What is the RBC hemoglobin content? o MCH or MCHC (chromic = color) o Normochromic: 31-37 o Hypochromic: <31 What is RDW (RBC distribution width)? o Index of variation in RBC size o Abnormal = > 0.15 proportion (15%) ▪ New cells differ in size ▪ Early indicator of evolving microcytic or macrocytic anemia What is reticulocyte percentage? o Body attempts to correct anemia o Normal 1-2% o Response to anemia is >2% o Reticulocytopenia - Low means body cannot fix the anemia

MICROCYTIC ANEMIAS ➢

Low MCV; Low MCHC o Thalassemia o Iron-deficiency ▪ Lead poisoning o Anemia of chronic disease

➢

Low H/H; High MCV o B12 deficiency o Folic acid deficiency ▪ Impaired liver ▪ Thyroid hypo-function ▪ Reticulocytosis

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Drug induced Macrocytosis without anemia o (ETOH >5 drinks in men > 3 drinks in women; carbamazepine, valproic acid, phenytoin; malabsorption, zidovudine (reversible, but meds outweigh the risks – DC ETOH – heavy alcohol intake has swollen cells) Hgb, Hct, RBC, MCHC, RDW) normal with ↑ MCV

➢ ➢

Serum iron – measure of iron in circulation Serum ferritin – < 15 (iron in storage) o Chronic smokers, COPD, high altitudes o Hct more than 48% women and 52% men o Hbg more than 16.5 women and 18.5 men Reticulocyte count – indicates ability of bone marrow to produce RBCs TIBC – total iron binding capacity o TIBC is ↑ when iron ↓ o TIBC is ↓ when iron ↑ High Altitude stress – low barometric pressure causes reduction in arterial PO2

MACROCYTIC ANEMIAS

LABS

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HERBAL MEDICATIONS WITH INCREASED BLEEDING RISK ➢ ➢

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Ginseng Gingko Fish oil

RBC TESTING Hemoglobin

Hgb electrophoresis MCV, MCH RDW Serum Fe TIBC Serum ferritin Ethnic ***Alpha thalassemia (Asians)

IDA Normal ↓ ↑ ↓ ↑ ↓ any

CBC, then iron studies, then Hgb electrophoresis HEMORRHAGE Blood loss of 15% or more. o Orthostatic hypotension o Signs and symptoms of shock

14-18 (males) 12-16 (females) Hematocrit 40-50% (males) 36-45% (females) MCV (average size of RBC) < 80 microcytic 80-100 normocytic > 100 macrocytic MCHC (average color of RBC) (↓ IDA, thalassemia) 31-37 normochromic MCH (indirect measure of color) (↓ IDA, thalassemia) 25-35 TIBC (capacity to seat iron – Iron count ↑ TIBC ↓) 250-410 ↑ IDA Normal thalassemia, vitamin B12 deficiency and folate deficiency Serum Ferritin (stored form of iron) **sensitive IDA 20-400 ↓ IDA Normal to high thalassemia Serum Iron 50-175 ↓ IDA RDW (variability in size) > 15% measure variability ↑IDA, Thalassemia Reticulocytes (immature – RBC survive 120 days) .5-2.5% Reticulocytosis (occurs w/ bone marrow stimulation) ↑ supplementation with iron, folate, B12, after acute bleeding, hemolysis, leukemia, erythropoietin (EPO) Poikilocytosis (peripheral smear) (shape) IDA Anisocytosis (variable size RBCs) Serum Folate 3.1-17.5 ↓ macrocytic anemia B12 250 ↓ macrocytic anemia

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➢

Nobody likes my educational background

COPD ↑ Chronic kidney disease ↓ Hypertension N/A DM with A1c 13.8 ↓ Aspirin use N/A Testosterone use ↑ Resident of Denver, CO ↑ 84 years old ↓ Meds that worsen anemia: ARB and ACEI in patients with CKD, diabetes, CHF, HTN

➢

HEMOGLOBIN ➢

EFFECT ON H/H

THALASSEMIA abnormal ↓ Normal Normal/↑ Normal Normal Asia, Mediterranean, North Africa, Middle East

HEMATOLOGICAL SYSTEM Electrophoresis gold standard o Sickle cell anemia o Thalassemia Secondary polycythemia o Chronic smokers, COPD, high altitudes o Hct more than 48% women and 52% men o Hbg more than 16.5 women and 18.5 men High Altitude stress – low barometric pressure causes reduction in arterial PO2 o CAD, CHF, sickle cell ↑ risk complications

Hemoglobin WBC TESTING Normal ➢ Electrophoresis gold standard5.0-10.0 x 10 ➢ Neutrophils 55-70% o Sickle cell anemia (AKA poly or segs) ****bands young Neut. o Thalassemia Bands > 6% (shift L) Lymphocytes 20-40% ➢ Secondary polycythemia (virus) o Chronic smokers, COPD, high altitudes ➢ Monocytes 2-8% o Hct more than 48% women and 52% men (debris) o Hbg more than 16.5 women and 18.5 men ➢ Eosinophils 1-4% (allergens, parasites, worms, pressure wheezes, ➢ High Altitude stress – low barometric causes weird diseases) reduction in arterial PO2 ➢ Basophils .5-1% Anaphylaxis not fully understood ➢ Leukocytosis (WBC > 10) – anticipated response in bacterial infections. ➢ Neutrophilia – elevated neutrophils ➢ Lymphocytosis – elevated lymphocytes ➢ Monocytosis - elevated monocytes ➢ Eosinophilia – elevated eosinophils ➢ Basophilia – elevated basophils

HEMATOLOGICAL SYSTEM

Name

Signs/Symptoms

Diagnostics

Neutropenia

Fever, sore throat, oral thrush

ANC less than 1500

Vit. B12 Deficiency

Deficiency in B12

Gradual onset symmetrical peripheral neuropathy numbness, ataxia, loss of vibration and position sense, impaired memory and dementia.

Stocking glove neuropathy, pale conjunctiva; systolic murmur, beefy red tongue

MCV > 100 Peripheral smear has macroovalocytes, megaloblasts and multisegmented neutrophils

Hodgkin’s Lymphoma

Cancer of beta lymphocytes

Night sweats, fevers, and pain with ingestion of alcoholic drinks; pruritus and painless enlarged lymph nodes (neck), anorexia and weight loss;

Non-Hodgkin’s Lymphoma

Cancer of lymphocytes and killer cells

night sweats, fever, weight loss, generalized lymphadenopathy (painless)

Multiple Myeloma

Cancer of plasma cells

Fatigue, weakness and bone pain usually located in back or chest; proteinuria with Bence-jones proteins; hypercalcemia, normocytic anemia;

Platelet count of less than 150,000

Asymptomatic until platelets lower than 100,000; easy bruising, bleeding gums, spontaneous nosebleeds, hematuria Bruising on distal lower and upper extremities is usually related to physical activity. Petechiae, purpura, large hematomas not accompanied by other symptoms are suspicious.

Iron Deficiency Anemia

Deficiency in ironmost common cause chronic low volume blood loss

Most common type of anemia in childhood, pregnancy and women during reproductive years.

Asymptomatic. Weakness, headache, irritability, skin pallor, fatigue, exercise intolerance, glossitis (red beefy tongue), angular cheilitis, cravings for pica. May cause spoon shaped nails, systolic murmurs, tachycardia, CHF, exacerbation of comorbid **common in alcoholic, NSAID users, females with heavy menses, vegans

Anemia of Chronic Disease

↓ renal EPO production

Most common type of anemia in elderly followed

by IDA and then pernicious anemia.

Thrombocytopenia

Cause

Treatments

Concerns

African Americans have lower ANC

Most common cause pernicious anemia Replace B12

Nerve damage (? Reverse if < 6 months) Advise vegans to take supplements ↑ incidence age 20-40 or >60 males, white

Prognosis is poor

Poor prognosis

>65 years

more common in elderly

Get better management of underlying disease.

Or diagnose the occult disease or illness.

Red blood cell life span is shortened from 100-120 days to 60-90 days

If bleeding - Check medications ASA, NSAIDs, Warfarin, SSRI, steroids. Check CBC, PT/PTT and R/O coagulation disorders

↓ Hgb ↓ Hct ↓ Serum Fe ↓Serum ferritin ↓MCV (microcytic) ↓MCH (hypochromic) ↑TIBC ↑RDW > 15% (if <15% old) Anisocytosis Poikilocytosis Most iron is obtained from recycled iron content from aged red blood cells

Iron rich foods – red meat, beans, green leafy vegetables, whole grains; *Need 150-200mg elemental iron daily.

Ferrous Sulfate 325mg PO TID take with OJ on empty stomach (65mg elemental iron per tablet) – recheck in 4-6 weeks.

(Rule of thumb Hct ↑ 3 pts. and Hgb ↑ 1 pt. – if not improved check reticulocyte count for possible bone marrow problem).

Treat for 3-6 months to replace iron stores.

Once anemia corrected = Ferritin for estimation of iron stores

Avoid iron supplement w/ antacids, dairy products, levothyroxine, quinolones or tetracyclines.

Serum iron is a drug level that fluctuates SE: constipation, black colored stools, upset stomach Store iron away from children due to toxicity Angular cheilitis – fungal infection. Tx with nystatin

Hgb ↓ 12 women; ↓ 13 men Normocytic, normochromic anemia, reticulocytopenia Check serum ferritin, TIBC, vitamin B12 and folate

Treatment aimed at control of underlying disease or diagnosing the occult disease or illness

HEMATOLOGICAL SYSTEM

Name

Cause

Thalassemia Minor

Genetic producing abnormal Hgb

Aplastic Anemia

Destruction of stem cells inside bone marrow (radiation, drug, viral infection)

Signs/Symptoms

Majority asymptomatic. Discovered due to abnormal CBC results revealing microcytic/hypochromic RBCs ***Cooley’s anemia is Beta Thalassemia Major – transfusion dependent anemia (found early in infancy)

Bone marrow production slows or stops Fatigue, weakness, pale color, tachycardia and systolic murmur; neutropenia, thrombocytopenia

Diagnostics

Treatments

Concerns

↓ Hgb ↓ Hct ↑ RBC ↓ MCV ↓ MCHC Normal RDW Normal to ↑ ferritin and iron Normal TIBC

Diagnostic test: Hemoglobin electrophoresis Beta-thalassemia (abnormal) IDA, normal (Blood smear: microcytosis, anisocytosis, poikilocytosis) Do not treat thalassemia Genetic counseling prior to pregnancy

If someone comes up positive screen the family At risk ethnic groups Alpha thalassemia: Asian, African ancestry (AAA) Beta thalassemia: African, Mediterranean, Middle Eastern (more common in US)

CBC w/ diff Platelet county Bone marrow biopsy (gold standard)

Refer to hematologist

Pancytopenia (leukopenia, anemia, thrombocytopenia)

Pernicious anemia

Autoimmune causing destruction of parietal cells; gastrectomy, vegans, alcoholics, bowel disease

Gradual onset of paresthesia on feet/hands, pallor, glossitis; numbness/tingling extremities, neuropathy, diff fine motor skills

B12/folate levels; B12 levels may be normal in 5% of patients with B12 deficiency Antiparietal and anti-intrinsic factor (IF) antibody test + 24h urine for methylmalonic acid, homocysteine level elevated, peripheral blood smear (macrocytosis)

Dietary deficiency may > 5 years to occur B12 sources: foods of animal origin (meat, poultry, eggs, milk, cheese) B12 via injections or nasal spray (1000mcg per week for 4 weeks then monthly for a lifetime) Oral 1000-2000mg daily Multivitamin with iron since IDA commonly coexist

Folic acid deficiency

Inadequate dietary intake causing damage to DNA or RBCs

Anemia, tired, fatigue, pallor, reddened sore tongue, glossitis, unexplained weakness, possible tachycardia, palpitations, angina or heart failure.

Macrocytic normochromic, peripheral smear – macroovalocytes folate levels <4

Body’s supply last 2-3 months Lifestyle changes (dietary – leafy green vegetables, grains, beef, liver) PO folic acid 1-5 mg/day Pregnancy 400 mcg daily

Sickle cell anemia

Genetic hemolytic anemia; variations in RBC – sickle shaped and insufficient of oxygen carrying capacity

Most asymptomatic; extreme anemia, frequent sickling episodes w/ pain, ischemic necrosis of bones or skin, renal/liver dysfunction, priapism, hemolytic episodes, hyposplenism, frequent infections – highly susceptible to infection. If fever give prophylactic PCN up to age 5

CBC Sickledex – screening Electrophoresis – gold standard Mean Hgb 8.0 RBC live 17 vs. 120 days

Refer to hematologist, Sickle cell disease is part of newborn screening; autosomal recessive (if each parent trait – one of four will have disease) prenatal screening available as early as 8-10 weeks via chorionic villus sampling or amniocentesis

Vitamin B12 deficiency (pernicious anemia, gastric disease, infections, antacids and metformin) Nerve damage from chronic B12 deficiency ↑ incidence in older women 2-3x ↑ gastric cancer **All dementia or patients with neuropathy need B12 levels checked Elderly, infants, alcoholics, overcooked vegetables, low citrus intake, malabsorption (gluten). Drugs that interfere: Phenytoin (Dilantin), sulfa, metformin, methotrexate, zidovudine 1 out of 500 African Americans in US have sickle cell anemia ↑ risk Strep pneumo, H. influenzae due to hyposplenia

MUSCULOSKELETAL SYSTEM ORTHOPEDIC MANEUVERS

SHOULDER

➢

Drawer Sign – knee instability/torn ligaments

➢

McMurray’s test – “click” on manipulation of knee with rotation of ankle; injury to medial meniscus tear

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Lachman’s sign – suggest ACL damage; more sensitive than drawer test

➢

Collateral ligaments – positive finding increase laxity of damaged knee. Valgus stress – MCL; Varus

➢

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

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Rotator Cuff Tear – lateral deltoid pain; pain and weakness, loss of strength in external rotation or abduction – usually disturbs sleep Adhesive capsulitis (Frozen Shoulder) – anterior shoulder pain; joint stiffness, measurable loss of movement in external rotation and abduction; common in diabetes AC OA – AC joint tenderness; osteophytes, joint space narrowing Extrinsic shoulder pain o Cervical nerve root compression • ROM of neck – precipitate pain? If yes; then neck problem Spurling o Myocardial ischemia; Splenic injury; Ectopic pregnancy

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stress test – LCL (Varus and Lateral) ➢ ➢

➢ Spurling Test ➢

Finkelsteins’s test – De Quervain’s tenosynovitis from inflammation of the tendon at base of the thumb. Pain w/ ulnar deviation

EXERCISE AND INJURIES ➢ ➢ ➢ ➢

Do not exercise the first 48 hours Use cold for first 48 hours RICE After 48 hours o Isometric exercises

TENDONITIS ➢

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Microtears on tendons causing inflammation and pain o Repetitive microtrauma, overuse or strain o Gradual onset o Acute pain with firm pressure applied to tendon o ↓ ROM caused by stiffness and discomfort o RICE Supraspinatus tendonitis – cuff tendonitis. Shoulder pain with certain movements such as elevation and abduction (reaching to the back pocket). Click when raise arm above head. Local point tenderness located on anterior area of shoulder o Contributors – swimming, throwing a football, pitching baseball, raking, washing cars or windows o Bursitis is common Epicondylitis – elbow pain o Lateral epicondylitis (Tennis Elbow) ▪ Gradual onset pain on outside of the elbow radiating to forearms. Overuse injury Pain worsens w/ twisting/grasping movements (opening jars, shaking hands); may have decreased hand grip strength; pain with wrist extension o Medical epicondylitis (Golfer’s Elbow) ▪ Gradual onset of pain in medial area of elbow; high risk baseball, bowlers, golfers; may have decreased hand grip strength ▪ 95% recover without surgery o Rest and keep joints moving o Complications – ulnar nerve neuropathy – numbness tingling of little finger and lateral side of ring finger with weakness of the hand.

▪ Permanent “claw hand” ▪ Tx with TCA, gabapentin, phenytoin and pain meds Tenosynovitis – Wrist tendonitis - ↓ ROM, swelling and muscle weakness

MUSCULOSKELETAL

OTTAWA RULES (SPRAINS) LOW BACK PAIN ➢

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Usually due to soft tissue inflammation, sciatica, sprains, muscle spasms or herniated discs (usually L4, L5 to S1 because hinge in back) (C6-C7) 90% of cases resolve within 1 month Risk factors: ↑ age, overactivity, obesity, DJD Most complain of stiffness, spasm, ↓ ROM Early lumbar radiculopathy – loss of DTR Further evaluation if: o Hx of significant trauma; infection o Suspect cancer metastases ▪ >50 with new onset back pain o Suspect spinal fracture (osteoporosis or chronic steroid use); Spinal stenosis (R/O ankylosing spondylitis); Symptoms worsen despite treatment Loss of posterior tibial reflex (L5) Loss of Achilles tendon reflex (L5 to S1) MRI Treatment depends on etiology o Uncomplicated – NSAIDs, warm packs for muscle spasms; ▪ Muscle relaxants ▪ After acute phase abdominal and core-strengthening ▪ Avoid bedrest due to deconditioning Spinal stenosis – pain improved when sitting down or leaning over Bulging disc – feels better when standing Complications – cauda equina syndrome Inspect, palpate, reflexes, strength, sensation, gait, straight leg raise = radiculopathy Waddell’s sign – overreaction during exam

BENIGN VARIANTS ➢ ➢ ➢

Genu recurvatum – hyperextension or backwards curvature of knees Genu valgum – knock-knees o “gum stuck between knees” Genu varum – bowlegs

➢ Grade 1 – mild – slight stretching and damage to ligament, stable joint. Able to bear weight and ambulate ➢ Grade 2 – moderate – partial tearing of ligament. Ecchymoses, moderate swelling, pain to palpation, weight bearing painful. Mild/mod joint instability. Consider x-ray/referral ➢ Grade 3 – complete rupture of ligaments and joint instability – inability to bear weight after injury, inability to ambulate at least 4 steps, tenderness over posterior edge of malleolus; severe bruising/pain, resists foot motion

RA vs OA Characteristic Primary joint affected

RA Hands; metacarpophalangeal

Heberden’s Nodes Joint Description Labs: RF, CCP, ESR, CRP

Absent Soft, warm, tender Positive

OA Weight bearing, carpometacarpal, DIP Usually present Bony and hard negative

MUSCULOSKELETAL SPORTS PARTICIPATION EVALUATION ➢

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Cardiovascular evaluation is an important component of sports physical o < 35 yrs. are mostly caused by cardiac malformations ▪ Hypertrophic cardiomyopathy o >35 yrs. are atherosclerotic CAD o Cardiovascular hx should include: ▪ Prior occurrence chest pain/discomfort, syncope ▪ SOB or fatigue with exercise ▪ Hx of heart murmur or elevated BP ▪ Family hx premature death, cardiovascular disease <50 yrs. of age o Cardiovascular physical examination ▪ Precordial auscultation supine and standing ▪ Assessment of femoral artery pulses to rule out coarctation of aorta ▪ BP sitting and standing HTN – avoid beta-adrenergic antagonist because of ability to blunt normal increase in heart rate; avoid diuretic if possible due to ↑ risk of dehydration Physiological murmur is ok – eval by cardiology Aortic Stenosis – play varies with degree Mitral Stenosis – play varies with degree Mitral regurgitation – mitral valve incompetency – regurgitation from left ventricle to left atria; commonly caused by rheumatic fever, endocarditis, calcific annulus, rheumatic heart disease, some mitral stenosis is usually present – play varies with degree of mitral regurgitation and ventricular chamber enlargement Mitral Valve Prolapse – most common valvular heart problem – common in pectus excavatum; ok to play if absence of symptoms of activity intolerance Hypertrophic cardiomyopathy – disease of cardiac muscle – can lead to sudden cardiac death; mid-systolic murmur that gets louder with standing Those with ICD should be aware of risk Septal/Atrial Defect – if repaired with little residual dysfunction, full sports is allowed; if no repair then degree should be assessed on individual basis; easily fatigued is a sign of atrial septal defect; child presentation can range from entirely well to heart failure A still murmur has a buzzing quality S2 split is occasionally found in uncorrected atrial septal defect Sinus Arrythmia should be encouraged to play Down syndrome needs cervical spine x-ray prior to sports (AAI)

FIBROMYALGIA RANDOM PEARLES ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

Pathological fracture – may be related to osteosarcoma or osteoporosis Stress fracture – overuse injury of bone o Take 6 weeks to heal DeQuervain’s Tenosynovitis – dorsal thumb pain o Use fingers a lot Contusion – bone injured but didn’t break Strain – injury to muscle Sprain – injury to ligament Cauda Equida syndrome – compression of spinal cord Vitamin D is recommended for all adults > 50 Risk factors for ankle sprain include: o Poor conditioning o Inappropriate footwear o Lack of warm-up period prior to exercising

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Mechanism unknown 4-7x more common in women More common in patients with autoimmune disease Widespread body aches, fatigue and cognitive changes Diagnosis involves identifying multiple tender points throughout body 11/18 o Apply enough pressure so that nailbeds blanch Physical activity aimed at ↑ flexibility Trigger point injection may be helpful Acetaminophen, NSAIDs, Trazodone, antidepressants, antiepileptics

TYPES OF SCANS ▪ ▪

▪

X-rays – bone fractures/damage, OA, metal, dense objects MRI – gold standard for injuries to cartilage, meniscus, tendons and ligaments o No metal, pacemakers, aneurysm clips CT – costs less than MRI, views structures likes masses, trauma, fractures, bleeding. Forms 3-D picture

Hook Test – Biceps Tear – MRI

ORTHO TERMINOLOGY ➢ ➢

Abduction (varus) – movement away from body Adduction (valgum) – movement toward the body

MUSCULOSKELETAL SYSTEM

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Navicular Fracture (Scaphoid)

Fall with outstretched hand

Pain on palpation of “snuffbox” area, pain on axial loading of thumb; pain worse when gripping or squeezing

x-ray initially may be normal; repeat in 2weeks

Splint wrist (thumb spica splint) refer to hand surgeon

Avascular necrosis and nonunion

Colles Fracture

Fracture of distal radius from fall

“dinner fork” fracture. Most common type fracture

Falls

Sudden onset on-sided hip pain. If mild may be able to bear weight. If displaced, inability to walk or bear weight on affected hip. Severe hip pain with external rotation of the hip/let and leg shortening

Hip Fracture

Pelvic Fracture

High-energy trauma (MVC)

Cauda Equina Syndrome

Depends on degree of injury and structures i.e.: nerves, blood vessels, organs. Ecchymosis and swelling in lower abdomen, hip, groin, scrotum.

Bladder/fecal incontinence, vaginal/rectal bleeding, hematuria, numbness.

Diagnostic Consideration Trochanteric bursitis Structural joint problem, OA Infectious, inflammatory, neoplastic Hip joint: OA, etc.

SI joint, LBP

More common in elderly 1-year mortality rate from 12-37% May cause internal hemorrhage - lifethreatening

Acute onset saddle anesthesia, bladder/fecal incontinence. Bilateral leg numbness and weakness, pressure on sacral nerve root causing inflammatory/ischemic changes to nerves.

Surgical emergency Refer to ED Needs spinal decompression RICE – Stop activity for several weeks Cold packs during acute exacerbation for 20 minutes several times a day Use cushioned soles Stretch before exercise and start at lower intensity

More common in runners and those with flat feet.

Female athlete triad: amenorrhea, eating disorder, osteoporosis

NSAIDs, Naproxen, diclofenac gel, orthotics, stretching. Refer to podiatry

↑ risk with obesity, diabetes, aerobic exercise, flat feet, prolonged standing

Avoid narrow/high shoes, use forefoot pad, well-padded shoes. Refer to podiatry

↑ risk with high heeled shoes, tight shoes, obesity, dancers and runners

Goals: Relieve pain, preserve joint mobility and function, minimalize disability and protect joint PT/exercise – weight bearing; weight loss if appropriate, Acetaminophen then NSAIDs; diclofenac gel to area, capsaicin cream; steroid injection on inflamed joint Glucosamine and chondroitin – mechanism unknown, QT prolongation.

AAAOS cannot recommend use

Large weight bearing joints (hips and knees) and hands are most commonly affected Risk factors ↑ age, overuse of joints, family hx

Medial Tibial Stress Syndrome or Fracture (Shin Splints)

Overuse resulting in microtears and inflammation of muscles, bones and tendons

Recurrent shin pain in one or both legs that becomes more severe over time. Pain along inner border of tibia and occurs during and after exercise.

Mild swelling and focal area of tenderness painful on palpation may suggest fx

Plantar Fasciitis

Microtears of plantar fascia

Plantar foot pain, unilateral or bilateral, worsened by walking or weight bearing. worse in morning or with prolonged walking

Morton’s Neuroma

Inflammation of digital nerve of the foot between 3rd and 4th metatarsal (nerve tumor)

Weeks of plantar foot pain worsened by walking (esp. high heels or tight narrow shoes); pain has numbness/burning located between 3rd/4th metatarsals on forefoot. “pebble-like” nodule

Damage of articular covered cartilage

Gradual onset: early-morning joint stiffness w/ inactivity. Short duration (<15 min). pain w/ overuse, swelling, tender to palpation. DIP common, May be unilateral – absence of systemic symptoms; pain awakens at night Heberden’s nodes (nodules on DIP) Bouchard’s nodes (nodules on PIP)

Degenerative Joint Disease (Osteoarthritis)

Hip Pain Location Lateral, aggravated by direct pressure Pain with use, better with rest Constant pain, especially at night Anterior hip/groin pain Posterior hip pain

X-ray will not show stress fx. Recommend bone scan or MRI

x-ray to r/o fractures, spurs

Mulder test (MTP squeeze) - grasp 1st/5th metatarsal and squeeze.

Positive if click along with patient report of pain x-ray- joint effusion, osteophytes and joint space narrowing r/o osteoporosis w/ bonedensity testing

MUSCULSKELETAL SYSTEM

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Autoimmune

Maculopapular butterfly shaped rash on middle of face (malar rash)- most evident after exposure to sun; nonpruritic thick scaly red rashes on sunexposed areas (discoid rash); fatigue, oral ulcers, gastritis, chronic inflammatory disease affects skin, joints, kidneys, lungs, nervous system and serous membranes

ANA ↑ ESR anemia U/A (+) for proteinuria

Refer to rheumatology Topical and oral steroids, Plaquenil, methotrexate, biologics (DMARDs) Education: avoid sun 10am-4pm Use nonfluorescent light bulbs

Characterized by remissions and relapses; more common in women in 20’s, 30’s Mild form cutaneous lupus erythematous; ↑risk miscarriage

Rheumatoid Arthritis

Autoimmune; multiple joint inflammation and damage

Gradual onset, fatigue, low-grade fever, body aches, myalgia, peripheral, polyarthritis >3 fingers/hands/wrist/ankles/feet/shoulders.

Morning stiffness last longer than 1-hour (longer than DJDs) w/ painful, warm and swollen joints. “sausage joints” – Swan neck deformities; Bouchard’s nodes

Symmetrical joint involvement and present for 6 weeks; ↑ ESR, CBC mild microcytic/normocytic anemia, rheumatoid factor positive, anti-CCP, radiographs space narrowing

Refer rheumatology NSAIDs, steroids, DMARD, antitumor necrosis (Humira, Enbrel)

Gout

Uric acid crystals within joints (great toe or fingers)

Painful, hot, red and swollen metatarsophalangeal joint of great toe (podagra). Limping from severe pain, hx or previous attack. Precipitated by alcohol, meats or seafood; meds that contribute include aspirin, diuretics, cyclosporine and niacin

Tophi on ears/joints; ↑uric acid level (test 2 weeks after attack); ↑ ESR Gold standard – joint aspiration

First goal – provide pain relief Indomethacin/Anaprox – colchicine Do not start allopurinol in acute phase (worsens); however, if patient already on allopurinol, do not discontinue Allopurinol/Probenecid for maintenance

Inflammatory disorder affecting spine

Chronic c/o back pain (>3 mon) worse in upper back. Joint pain worse at night; low-grade fever, fatigue, chest pain w/ respiration, long-term stiffness improving with activity, some buttocks pain, loss of ROM, Uveitis/eye irritation/photosensitivity

↑ESR, CRP, RF negative, “bamboo spine” on spinal radiograph

Refer to rheumatology NSAIDs (injure GI by blocking COX-1 and COX-2 resulting in ↓ prostaglandins) If uveitis refer to ophthalmology

Meniscus Tear (of knee)

Trauma or overuse (twisting of knee)

Locking of knee, popping or giving out. Some patients are unable to fully extend affected knee.

Patient may limp. Complains of knee pain and difficulty walking and bending the knee. Some complain of joint line pain

McMurray then ask patient to squat; Apley grinding test; ↓ ROM x-ray but meniscus will not show up; MRI

RICE, joint effusion may be present, but aspirate only if no improvement in 2-4 weeks; Crutches and knee immobilizer; straight leg raises help strengthen quads Refer to ortho

Bursitis (Ruptured baker’s cyst)

Rupture of bursa behind knee

Active patient complains of “ball-like” mass behind knee, may be asymptomatic. If cyst ruptures will cause inflammatory reaction like cellulitis of area (redness, swelling, tenderness)

Clinical presentation MRI r/o septic joint

RICE, NSAIDs, large bursae can be drained If cloudy fluid, C&S to r/o sepsis

Sarcoidosis

Inflammatory condition resulting in production of noncaseating granulomas predominately lungs, lymph nodes, eyes, skin

Can develop gradually with symptoms that last for years or have more rapid progression and resolution of disease. Fever, fatigue, anorexia and arthralgias, rash, lesions, color change, nodule formation under skin, blurred vision, eye pain, severe redness and sensitivity to light

Serum amyloid A; Soluble interleukin 2 receptor; ACE Glycoprotein KL-6; Hypercalcemia; Hypercalciuria Chest x-ray; CT chest; PFT; biopsy

Often self-limiting; NSAIDs; Corticosteroids orally, cream, inhaled Plaquenil, DMARDs Lung transplant

Adults 20-40; women and African Americans more common

Acute nonpurulent arthritis

2+, with at least one musculoskeletal: asymmetrical oligoarthrtitis, predominately lower extremity, sausage shaped finger (dactylitis); toe or heel pain; cervicitis, prostatitis, acute diarrhea within one month, conjunctivitis or uveitis, genital ulceration, urethritis; joint pain knee/ankle/feet

With diarrhea affects genders equally; with urethritis (male dominance) with HLA-B27 positive; culture of joints negative

NSAIDs, systemic corticosteroids, tumor necrosis factor blocker (etanercept or infliximab); Urethritis treated with doxycycline x 7 days or azithromycin single dose

Often seen days to weeks after diarrhea caused by Shigella, Salmonella or Campylobacter or Chlamydia

Systemic Lupus erythematosus (SLE)

Ankylosing Spondylitis

Reactive arthritis (formerly Reiter Syndrome)

Uveitis (eye pain with conjunctival injection – no purulent drainage), scleritis, pericarditis, malignancies Peak age 20-40 Joint destruction More common in middle aged men 30+; obesity Pseudogout – calcium pyrophosphate dihydrate, linked with parathyroid Anterior uveitis (eye pain with conjunctival injection – no purulent drainage), aortitis, fusing of spine w/ ROM loss/spinal stenosis

PSYCHOSOCIAL MENTAL HEALTH

COMMON SSRIS (listed from most to least energizing)

INCREASED RISK OF SUICIDAL THINKING IN THOSE LESS THAN 24 YEARS

First line tx for major depression, OCD, anxiety and premenstrual disorder ➢ Fluoxetine (Prozac) longest ½ life (interacts with coumadin) ➢ Sertraline (Zoloft) ➢ Citalopram (Celexa) few drug interactions, QT prolongation (max dose 20 elderly) ➢ Escitalopram (Lexapro) ➢ Paroxetine (Paxil) shortest ½ life (lots drug interaction and sedating – Erectile Dysfunction and anticholinergic effects) Best effect on lifting and smoothing mood ***Can induce mania w/ bipolar. Do NOT combine with MAOIs ***40% chance sexual adverse effects

DEPRESSION SYMPTOMS ➢ S – Sleep – insomnia or hypersomnia ➢ I – Interest– less interest in activities, irritability (anhedonia) ➢ G – Guilt – worthlessness or inappropriate guilt ➢ E – Energy – fatigues ➢ C – Concentration – diminished ➢ A – Appetite – weight change, loss or gain ➢ P – Psychomotor – agitation or retardation ➢ S – Suicide – recurrent/obsessive thoughts ➢ M – Mood – depressed mood, tearful

COMMON SNRIS ➢ ➢

Venlafaxine (Effexor) ↑ BP Duloxetine (Cymbalta) neuropathy (avoid in alcohol users) ➢ Desvenlafaxine (Prestiq) Best effect on lifting and smoothing mood plus increase focus ***40% chance sexual adverse effects

Major depression: > 5 symptoms Minor depression: 2-5 symptoms r/o hypothyroidism, anemia, autoimmune, B12 def.

S/S in teens: failing grades, acting out, avoiding socialization, moodiness.

ANXIETY SYMPTOMS ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

W – Worry A– Anxiety T – Tension in muscles C – Concentration difficulty H – Hyperarousal or irritability E – Energy loss R – Restless S – Sleep disturbance

➢ > 3 of the following occurring on most days > 6 months

TREATMENT GOALS ANXIETY/DEPRESSION ➢ Remission of symptoms for > 4-5 months aimed at elimination and restorative health o Most often achieved with psychologic, social services and medications o Slowly taper off meds ➢ Consider longer-term therapy if > 2nd episode

QUESTIONS TO ASK PRIOR TO RX ➢ What are the most bothersome symptoms? ➢ What meds will help with these symptoms?

SDRI ➢

Bupropion (Wellbutrin) avoid seizures/bulimia ➢ Usually used as add-on to SSRI Best effect on improving mood with insufficient response with SSRI ***20% chance sexual adverse effects

ANXIOLYTICS ANTIDEPRESSANT DISCONTINUATION ➢

TCA ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

Not first line for depression Postherpetic neuralgia, stress incontinence Avoid if ↑ risk for suicide Overdose = fatal cardiac, neurological effects, SE = Anticholinergic, hypotension, conduction arrhythmia, glaucoma, BPH, confusion Migraine prophylaxis Imipramine, amitriptyline and nortriptyline Avoid in CV disease, elderly (BEERS)

➢ ➢ ➢ ➢ ➢ ➢ ➢

SSRI, SNRI, TCA > 6 months then discontinued.

Typically, last < 7 days. Taper over 6 weeks to reduce symptoms. Bothersome, not life threatening.

F – Flu-like symptoms I – Insomnia N – Nausea I – Imbalance (dizziness, difficult coordination) S – Sensory disturbance H – Hyperarousal (anxiety/agitation) H – Headache

➢ Benzodiazepines (use long acting to avoid abuse) o ↓ dose by 25% each week when dc ➢ Buspirone (BuSpar) -low abuse potential o Potentially helpful if taken 3x daily for 6 weeks or longer (useless as prn & for sleep)

MAOI ➢ ➢ ➢ ➢

Food and drug interactions Phenelzine (Nardil) and tranylcypromine (Parnate) Do not combine with SSRI, TCA, triptans Elevates BP and risk of stroke when used with fermented foods such as beer, wine, cheese

PSYCHOSOCIAL MENTAL HEALTH

ALCOHOL SCREENING ➢ C: Do you feel the need to cut down? ➢ A: Are you annoyed when your friends/spouse comment about your drinking? ➢ G: Do you feel guilty about your drinking? ➢ E: Do you need to drink early in the morning? ➢ Positive response to 2/4 is highly suggestive of alcohol abuse ➢ Anyone feeling compelled to drink no matter what the consequences is addicted

ANTIPYSCHOTICS SIDE EFFECTS ➢ Pill rolling, shuffling gait, bradykinesia ➢ Extrapyramidal symptoms: o Akinesia - inability to initiate movement o Akathisia - strong inner feeling to move, unable to stay still o Bradykinesia - slowness in movement when initiating activities that require successive steps such as buttoning a shirt o Tardive dyskinesia - involuntary movements of lips (smacking), tongue, face, trunk and extremities ➢ Increased risk of obesity, Type 2 DM, hyperlipidemia, metabolic syndrome and hypothyroidism

SUICIDE ➢ Males represent nearly 80% of all completed suicides. ➢ Females attempt suicide 2-3 times more often. ➢ Highest rate of completed suicide is found in elderly males (75+). ➢ Inquiring about suicidal ideation DOES NOT lead to suicide. ➢ Risk Factors: o Older people who have lost a spouse o Plan involving gun or lethal weapon o Hx of attempted suicide o Mental illness: bipolar, depression o Hx of sexual, emotional or physical abuse o Terminal illness, chronic illness, pain o Significant loss o Bipolar is higher risk during depressive episode ➢ 3 important questions: o Are you thinking of hurting yourself? o If yes, do you have a plan? o If yes, do you have the means? ➢ Imminent risk o Immediate psychiatric referral, inpatient hospitalization ➢ Elevated risk but not imminent o Aggressive treatment

SEROTONIN RECEPTOR SITES ➢ 5-HT1A – antidepressant ➢ 5-HT1C, 5-HT2C – cerebral spinal fluid production ➢ 5-HT1D – antimigraine effect (anti=defense) ➢ 5-HT2 – agitation, anxiety, panic (2 stressed) ➢ 5-HT3 – nausea, diarrhea (3 GI N/V/D)

ALTERNATIVE MEDS FOR DEPRESSION ➢ St. John’s wort o Interacts with SSRI, TCA, MAOI o ↓ Digoxin effectiveness o ↓ effectiveness of birth control ➢ 5-HTP, L-tryptophan o Interacts with SSRI, MAOI, dextromethorphan, Triptans ➢ Omega-3 fatty acids o No major drug interactions o High doses may ↑ risk of bleeding o Stop 1 week before surgery ➢ Folate and vitamin B6 ➢ Exercise, yoga, massage, guided imagery, acupuncture, light therapy ➢ Kava-Kava and valerian root are both used for anxiety and insomnia. Do not mix with benzos, hypnotics or any CNS depressants

MOOD ➢ Monoamine System o Serotonin (5-HT) ▪ Well being ▪ Calm ▪ ↓ impulsivity ▪ ↓ sex drive ▪ ↓ aggression ▪ ↑ appetite o Dopamine ▪ Make you worry ▪ ↑ vigilance ▪ ↑ motivation o Norepinephrine ▪ Enhance concentration ▪ Enhance ambition ▪ Enhance productivity

PSYCHOSOCIAL MENTAL HEALTH

Name

Cause

Signs/Symptoms

Bipolar Disorder

Strong genetic component

Type 1: classic manic episode: labile moods, euphoria, talkativeness, flight of ideas, grandiosity and less need for sleep; increased energy/activity, disinhibition. May have psychotic episodes. ↑ rates of substance abuse Type 2: hypomanic episode – hypomanic disorder, absence of mania and major depression

Peak onset in 20s

Acute Serotonin Syndrome

High levels of serotonin from new drugs or dosage change

Acute onset high fever, muscular rigidity, mental status changes, hyperreflexia, uncontrolled shivering, dilated pupils, tachycardia, diarrhea

Acute onset with rapid progression.

Idiopathic

Antipsychotics affect dopamine in brain.

Sudden onset high fever, muscular rigidity, changes in mental status, fluctuating BP and urinary incontinence

Malignant neuroleptic syndrome

Depression

30-40% genetic 60-70% life events

Sleep, interest, guilt, energy, concentration, appetite, agitation, suicide, mood (generally, complain of headache, back pain, chronic pain, “tired all the time” with consistent early morning wakening) Seasonal affective disorder – common in winter (exercise and SSRI) ↑ risk for suicide in older men

Dietary Guidelines: Women 1 drink per day; Men 2 drinks per day – women metabolize alcohol 50% slower than men Binge drinking: Men 5+ drinks, women 4+ Acute delirium tremors – sudden onset confusion, delusions, auditory, tactile or visual hallucinations, tachycardia, HTN, tremors, picking, grand mal seizures Peak symptoms within 24-36 hours after alcohol is discontinued

Alcoholism

Compulsive desire to drink despite personal, financial and social consequences

Korsakoff’s syndrome (Wernicke-Korsakoff)

Complication from chronic alcohol abuse (thiamine – vitamin B1)

Neurological disorder - hypotension, visual impairment and coma; mental confusion, ataxia, stupor.

Korsakoff’s amnesic syndrome

Chronic thiamine deficiency damaging brain permanently

Problems with acquiring and learning new information (antegrade amnesia) and retrieving old information (retrograde amnesia). confabulation, disorientation, attention deficits, visual impairment

Diagnostics

Treatments

Medications: Lithium (adverse effects kidney and thyroid) Anticonvulsants (valproate, carbamazepine) Antipsychotics (treat manic episodes) Benzodiazepines (insomnia, agitation, anxiety) ↑ risk if combining medications SSRI, MAOI, TCAs If switching medications wait a minimum of 2 weeks.

Concerns

High risk for suicide during depression phase

Life-threatening

Life-threatening

Must include depresses moor or loss of interest or pleasure Major: > 5 symptoms Minor: 2-5 symptoms R/O hypothyroidism, anemia, autoimmune, vitamin B12 CBC, CMP, TSH, Folate, B12, UA, UDS (EKG if giving something to prolong QT interval)

GGT – lone elevation sign of abuse AST/ALT ratio – 2:1 ALT more specific for liver AST found liver, cardiac, kidneys, lungs and skeletal muscle MCV > 100 due to folate deficiency

If patient is harm to self or others, refer to psychiatric hospital. “Baker Act” – 3 days involuntary detention for evaluation and treatment of those at high risk.

Screening tools – Beck Depression inventory, PHQ9 Cognitive Behavioral Therapy SSRI 1st line – 4-12 weeks to take effect TCA prior to bedtime due to sedation (avoid TCA with suicidal) If sexual dysfunction, consider adding Wellbutrin Refer to AA, Al-Anon family groups Benzos such as Librium, Valium – antipsychotics if needed (Haldol).

Avoid RX for potential abuse such as narcotics or alcohol (cough syrup) Lorazepam if treating alcohol withdrawal and hepatic dysfunction; clonidine for tremor and tachycardia Disulfiram (Antabuse) – causes N/V, headache Naltrexone (Vivitrol); acamprosate (Campral) – decreases alcohol cravings High dose parenteral vitamins, especially thiamine (vit. B1)

Permanent due to thiamine deficiency

USPTF recommends screening every adult for depression Comorbidities: anxiety, PTSD, OCD, ADHD, oppositional defiant disorder, alcohol and drug disorders St John’s Wort interacts with oral contraceptives, cyclosporine and select antiretrovirals

Levels > 0.8% for driving Beer – 12 oz Wine 5 oz Liquor 1.5 oz

can lead to Wernicke Encephalopathy (B1 is sugar for the brain)

PSYCHOSOCIAL MENTAL HEALTH

Name

Insomnia

Cause

Circadian rhythm disorders, psychic issues, mental illness, OSA, RLS, environmental factors, certain medications, idiopathic.

Signs/Symptoms

7-8 hours of sleep is the ideal amount. Difficulty falling asleep or waking up during night too early and unable to go back to sleep; daytime drowsiness, fatigue, headache, irritability, difficulty concentrating

Schizophrenia

Delusions and paranoia (disorganized speech and behavior). Hallucinations are common (usually auditory) with loss of ego boundaries; flat and restricted affect with poor social skills, ability to plan and organize day-to-day activities (executive skills) are poor

Anorexia Nervosa

Secretive, perfectionistic and self-absorbed.

Marked weight loss (BMI <18.5), lanugo on face, back, shoulders, amenorrhea for 3 mon or longer, abdominal distention with hepatomegaly, cheilosis, oral and gum disease, coarse dry skin, hypotension with bradycardia and hypothermia If purging - loss of dental enamel. Engage in severe food restriction or binge eating and purging. Some use laxatives, vomiting and excessive daily exercise.

Onset teens to early 20’s

Irrational preoccupation with intense fear of gaining weight with distorted perception of body shape and weight

Diagnostics

Primary – not caused by disease or environment Secondary – caused by disease or environment Short term – less than 3 months, pain, stress, grief Chronic – at least 3 months, occurs at least 3 nights per week

•

• •

DSM V: Inability or refusal to maintain body weight at or above minimum normal weight for age and height Intense fear of gaining weight and becoming fat despite low body weight Disturbance in perception of body weight and shape

Treatments

Sleep hygiene (regular time, avoid caffeine, Refer to sleep lab (polysomnography is gold standard for sleep apnea) Antihistamines (careful w/ Benadryl in elderly) Benzo hypnotics: Short acting: Alprazolam, Triazolam, Midazolam Intermediate acting: Lorazepam, temazepam Long acting: Diazepam, clonazepam, chlordiazepoxide (Halcion and temazepam are more sedating) Non-Benzo hypnotics: adverse effects include agitation, hallucinations, nightmares, suicidal ideations. Awakening and cannot recall event.

Zolpidem (Ambien) – sleep onset or inability to stay asleep Eszopiclone (Lunesta) – sleep onset or inability to stay asleep Ramelteon (Rozerem) – sleep onset insomnia (melatonin agonist) Complementary: Kava-Kava, Valerian root (do not give to children or lactating/pregnant & do not mix with benzos or hypnotics), Melatonin, Chamomile tea, meditation, yoga, Tai-Chi, acupuncture, regular exercise (avoid 4 hours prior to bedtime) Refer to psychiatrist Use of typical antipsychotics can increase sudden death Antipsychotics can prolong QT intervals (EKG needed) and can cause torsade de pointes – clozapine, thioridazine, ziprasidone, haloperidol and others

SSRI 1st line Wellbutrin contraindicated– increases seizure threshold Chvostek’s sign – contract of facial muscles when facial nerve is tapped briskly – associated with hypocalcemia which could further develop to tetany

Concerns

Risk factors: depression, anxiety, GERD, female, illicit drug use, musculoskeletal illness, pain, chronic health problems, shift work, alcohol, caffeine and nicotine. (certain medications – SSRI, cardiac, BP, allergy and steroids can cause insomnia)

Onset is usually 16-30’s

Onset usually during adolescence Osteopenia/osteoporosis due to prolonged estrogen depletion from amenorrhea and low calcium intake, peripheral edema due to low albumin from low protein intake, cardiac complications – arrhythmia, cardiomyopathy, hypokalemia

PSYCHOSOCIAL MENTAL HEALTH

Name

Cause

Signs/Symptoms

Diagnostics

•

Secretive disease. Problems with erosion of lingual surface of upper teeth due to excessive exposure to gastric contents during vomiting.

Hypokalemia caused by laxative and diuretic use is common. Pt is typically of average to slightly above average weight.

Bulimia Nervosa

• •

•

DSM V: Eating excessing amount of food in 2 hours Person feels lack of control over eating Recurrent compensatory behavior to prevent excessive weight gain such as vomiting, excessive exercise, laxative or diuretic abuse or fasting Occurs once per week for at least 3 months

PTSD

Combat/war, sexual assault, MI, stroke, ICU stay

Flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, agoraphobia, sleep disturbance and hypervigilance, feelings of detachment

Assessment tools such as PTSD checklist

Anxiety

Situational, Phobias, OCD, Generalized

Panic disorder occurs more in women than men with agoraphobia

GAD – excessive worry occurs on more days than not for 6 months

Munchausen Syndrome

Factitious disorder imposed on self. Patient falsifies symptoms and or injures self-seeking medical treatment.

Treatments

Cognitive behavior and pharmacological therapy. SSRIs – but NOT Wellbutrin

First line treatment is SSRI such as paroxetine and sertraline. Therapeutic trial of 6-8 weeks to determine effectiveness.

Mirtazapine for sleep. Cognitive behavioral therapy, Eye movement desensitization and reprocessing (EMDR).

Benzos – limited duration, addiction concern behavioral treatment and SSRI to kick in and then wean off Benzo GAD – SSRI, SNRI, buspirone Panic disorder – SSRI, SNRI, TCA, BB, MAOI OCD – SSRI, SNRI, TCA

Concerns

Binge eating is lack of control over amount and type of food 2+ times per week for 6 months.

Accompanied by distress, self-anger, shame and frustration because of purging. Pt is usually obese.

Comorbidities such as depression, anxiety, antisocial disorder and substance abuse is higher

Herbs: Kava-kava, valerian root and passion flower

Munchausen syndrome by proxy (makes the child sick)

TOBACCO CESSATION ➢ 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 ➢ Nicotine patches – do not use with other nicotine products. Nicotine overdose can cause acute MI, HTN, agitation. ➢ 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. ➢ 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 ➢ Physical, emotional and sexual abuse, economic abuse, material exploitation o Can happen at any age (↑ risk with pregnancy) o Pattern of injury is inconsistent with story ➢ Factors that increase likelihood of abuse o Increased stress o Alcohol and drug abuse o Personal hx of abuse, family hx of abuse o Major loss o Social isolation o Pregnancy o Elderly (especially those who are frail with dementia) ➢ Physical Exam o Another health care provider should be in the room during exam o Interview with abuser and then without o Collect visual evidence, photos, use ruler. Document in direct quotes. o Look for spiral fx, multiple healing fx, burns, welts, etc. o Look for signs of neglect o Develop a safety plan with partner abuse o STD testing ➢ State things objectively, do not be judgmental ➢ Abuser is typically dominant in conversation ➢ BATHE o Background – how are things at home? Work? Anything changed? o Affect, anxiety – how do you feel about home life? Work? School?

Life in general? o Trouble – What worries you the most? o Handling – how are you handling the problems? o Empathy – that sounds difficult ➢ 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

DSM CRITERIA FOR SUBSTANCE ABUSE DISORDER ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

➢

Require 2 or more of the following within past 12 months Substance use in larger amounts over longer period than intended Desire to cut down or has tried unsuccessfully in the past Excessive time spent obtaining substance, using substance or recovering from substance Craving or a strong desire to use Inability to maintain major role obligations Continued substance use despite recurrent social or interpersonal problems related to substance use Substance use in potentially hazardous positions Important social, occupational or recreational activities are given up or reduced due to substance use Tolerance o Needing more to get same effect o Diminished effect with same amount Withdrawal o Set of characteristic withdrawal symptoms o Same or other substances taken to avoid withdrawal

RANDOM SUBSTANCE ABUSE FACTS ➢ ➢ ➢ ➢ ➢

Often have underlying mood disorder Young adults (18-25) are most likely to misuse RX meds Chronic used of marijuana can lead to COPD Alternative to methadone is buprenorphine plus naloxone Hyperthermia and racing heart is potentially life threatening with MDMA (ecstasy or Molly)

RENAL

KIDNEYS ➢ ➢ ➢ ➢

➢ ➢ ➢

Body’s regulator of fluids Water is reabsorbed by antidiuretic hormone and aldosterone Excrete water-soluble waste (creatinine, urea, uric acid) Produce erythropoietin (stimulates bone marrow to produce more RBC), renin, bradykinin, prostaglandins and calcitriol/vitamin D3 Average UO is 1500 mL Oliguria < 400 mL day Right kidney sits lower than left due to liver displacement

KIDNEY FUNCTION ➢

➢

URINALYSIS ➢ ➢

➢ ➢ ➢

➢ ➢

Epithelial Cells – large amounts indicate contamination; a few are normal Leukocytes – normal WBCs in urine <10 o Leukocyte esterase o Pyuria (presence of leukocytes) in males is always abnormal Urine for Culture and Sensitivity o >100,000 Red Blood Cells o <5 is normal Protein o Indicates kidney damage o Urine dipstick detects albumin not microalbumin (Bence-Jones proteins) Nitrites o Indicative of infection Cast o Hyaline cast are normal o WBC cast may be seen with infection o RBC cast and proteinuria are diagnostic of glomerulonephritis

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Serum Creatinine – when renal function ↓ creatinine ↑ Creatinine affected by age (less sensitive in elderly), gender (higher in males), ethnicity (high with African background), muscle mass Male 0.7 to 1.3 Female 0.6 to 1.1 Estimated Glomerular Filtration Rate (eGFR) eGFR “estimated value” – more damaged the kidneys, the lower the eGFR. Best if patient does not eat meat 12 hours before test and is less reliable with drastic changes in muscle mass, pregnancy and acute renal failure normal eGFR > 90 Stage 2 eGFR 60-89 Stage 3a eGFR 45-59 Stage 3b eGFR 30-44 Stage 4 eGFR 15-30 Stage 5 eGFR < 15 Blood Urea Nitrogen – elevation may be caused by acute renal failure, high-protein diet, hemolysis, CHF or drugs (waste product of protein from foods eaten, dehydration will also elevate BUN) BUN-to-Creatinine Ratio – evaluate dehydration, hypovolemia, acute renal failure

CHRONIC KIDNEY DISEASE ➢

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KIDNEYS ➢

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Prerenal azotemia – most common cause of acute renal failure, kidneys are hypoperfused – which leads to acute tubular necrosis. Caused by ↓ circulating volume such as dehydration and acute blood loss; ↓ CO such as heart failure; excessive sequestering of fluids as in burns Postrenal azotemia – obstruction to urine flow and is uncommon cause of renal failure. Such as glomerulonephritis

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Common electrolyte disorders include hypernatremia, hypercalcemia and hyperkalemia Increase in creatinine from 1-2 indicates a 50% loss in renal function Creatinine clearance usually approximates eGFR Creatinine is best described as a product related to skeletal muscle metabolism Common causes include DM, recurrent pyelonephritis, polycystic kidney disease Persistent proteinuria is commonly found in early development of CKD ACEI can limit the progression of some renal disease by reducing efferent arteriolar resistance Objective findings in glomerulonephritis include edema, RBC cast and proteinuria Anemia: Normocytic, normochromic anemia with low retic count Erythropoiesis is recommended with CKD and Hgb < 10 Dialysis and transplant discussion at Stage 4 CKD Some meds that affect kidneys – Allopurinol, antibiotics, digoxin, lithium, gabapentin, H2 blockers, antiarrythmias

RENAL

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Pyelonephritis

E. Coli, Klebsiella spp.

Proteus mirabilis

High fever, chills, dysuria, frequency, and unilateral flank pain (described as deep ache) N/V May have had recent UTI

CVA tenderness UA – large leukocytes, hematuria, WBC cast and proteinuria Urine C&S

Uncomplicated may treat as outpatient Cipro BID x 7 days or Levaquin daily Rocephin 1 gram + Augmentin BID x 14 days

Decreased blood flow to kidneys; damage to kidneys; urine blockage in kidney

Abrupt onset of oliguria, edema and weight gain (fluid retention). Complains of lethargy, nausea and loss of appetite. Rapid ↓ in renal function

↑ creatinine ↓ GFR

Hydrate

Bladder cancer

Long term use with pioglitazone

Painless hematuria (microscopic or gross). May appear at the end of voiding. Dysuria, frequency, nocturia (not related to UTI). Advanced disease may complain of lower abdominal or pelvic pain, perineal pain, low-back pain or bone pain.

UA – microscopic hematuria is the primary finding in 20% of individuals with bladder CA Urine C&S Urine for cytology

Preferred therapy for nonmuscularinvasive bladder cancer without evidence of metastasis is transurethral resection with intravesical chemotherapy. Despite successful initial therapy, local recurrence is common

Hematuria

Cancer, infection, renal calculi, coagulopathy, glomerular disease, hydronephrosis, polycystic kidneys, trauma, medications, BPH, exercise induced

Gross hematuria if urine is pink, red, brown or blood clots are present.

UA If infection: Urine C&S If malignancy: Urine for cytology

Acute renal failure

Urinary Tract Infection (Cystitis)

E. Coli, Klebsiella spp.

Staph. Saprophyticus, Proteus mirabilis

Frequency, burning, urgency, dysuria, hematuria, foul-smelling urine, nocturia, lower abd. /back pain – NO FEVER Risk factors: female, pregnancy, hx of UTI, DM, failure to void after sex, spermicide use, low fluid intake, poor hygiene, catheterization

UA moderate to large leukocytes, +/- nitrites, few RBC (inflammation) C&S > 100,000 UTI never normal in male – R/O other causes.

3 or more UTI in 1 year in females – R/O other causes ***nitrates are normal in urine, nitrites can indicate infection

Nephrolithiasis (Urolithiasis)

Glomerulonephritis

Majority made of calcium oxalate; Struvite stones are found in those with hx of kidney infection

Inflammation of glomeruli in kidney.

Occurs 1-2 weeks s/p bacterial infection

Severe colicky pain that comes in waves. Patient cannot sit still. Pain builds in intensity, lessens and disappears. Associated with N/V. May have gross or microscopic hematuria Stones in upper urethra or renal pelvis may cause flank pain and tenderness whereas stones in lower urethra may cause pain radiating to testicle or labia. Both can cause abdominal pain

Pink or cola colored urine due to hematuria, foamy due to proteinuria, HTN, edema of face, hands, feet and abdomen, possible anemia

UA ↑ Protein, RBCs, renal cast ↑ Creatinine and BUN CT scan or kidney sono Confirmatory diagnosis is with Kidney biopsy

Uncomplicated: Bactrim DS BID x 3 days; (sulfa allergic/resistance) Nitrofurantoin (Macrobid) 100mg BID x 5 days Ciprofloxacin (Cipro) 250mg PO BID – no fluoroquinolones in pregnancy or <18yo Pyridium – leaves it orange (avoid in liver disease) Complicated: Keflex, Cipro 500mg BID or Levaquin 750 daily for 7-10 days ***Nitrofurantoin contraindicated with renal insufficiency

Concerns

Risk factors: Elderly > 50; male (73 years), smoker, occupational exposure to textile dyes and heavy metals

For men do prostate exam Only treat pregnant women with asymptomatic bacteriuria UTI in pregnant women and children <3 are more likely to progress to pyelonephritis Renal and bladder sono for UTI infants

Toradol injection Increase fluids, strain urine Avoid high-oxalate foods: rhubarb, spinach, beets, chocolate, tea and meats Consider alpha blocker Refer urology

Risk factors: family hx of stones, gout, bariatric surgery, high doses vitamin C Meds that cause kidneys stones: HCTZ, topiramate, indinavir

Acute is often self-limiting. Manage underlying cause and protect kidneys – antihypertensives, antimicrobials, systemic corticosteroids and immune suppressants. Plasmapheresis, dialysis If left untreated, can lead to kidney failure, HTN, electrolyte disorders and nephrotic syndrome

Risk factors include infection: bacterial endocarditis, immune disease: Goodpasture’s syndrome, SLE, or vasculitis: polyarteritis or Wegener’s granulomatosis

WOMEN’S HEALTH

RANDOM GU Normal healthy women of reproductive age ➢ Discharge – white, clear, flocculent (1/2 to 1 tsp daily) ➢ Normal pH – 3.8-4.2 If test positive for STI then also recommend o Syphilis, HIV and Hep B testing Friable cervix – brisk bleeding with cleaning with cotton swab o Increased chance to acquire STI Normal findings on pelvic exam in older woman o Flattening of vaginal rugae o Scant white vaginal discharge o Should not be able to palpate ovary

URINARY INCONTINENCE Types Stress incontinence Overflow incontinence

Urge incontinence

Functional incontinence

Mixed incontinence

Definition Associated with lifting, laughing, sneezing, bending Frequent dribbling; due to blockage of flow Reports of strong sensation of needing to void. “overactive bladder” – detrusor instability Often occurs in presence of mobility problems

Stress and urge incontinence

Management Pelvic floor exercises, decongestant?

Identify & treat underlying cause (BPH, MS, spinal cord injury) Antimuscarinic (oxybutynin/Ditropan) or TCA (imipramine), Kegels Bedside commode, raised toilet seats with handles, physical therapy for strengthening and gait Kegels

Age Peak 45-49 yrs.

Older men

Older women

Treatable Causes of urinary incontinence: D – Delirium 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 ➢ ➢ ➢

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During gynecological exam, instruct patient to cough (↑ intra-abdominal pressure so herniation is visible) Herniation of bladder (cystocele) – bulging anterior vaginal wall – refer for pessary placement, surgery 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 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 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

WOMEN’S HEALTH

BREAST CANCER ➢ ➢

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BRCA (breast cancer susceptibility gene) High risk o Family history of breast cancer (before 50) o Breast cancer triple-negative (before 60) o Ovarian or other gynecological cancer o ↓ parity, early menarche, late menopause Men with BRCA genes are higher risk of breast and prostate cancer Refer high risk to breast specialist Screened using MRI and mammogram – screen 10 years earlier than when family member diagnosed More common among Ashkenazi Jews

CERVICAL CANCER ➢ ➢

CERVIX ➢

Cervical ectropion – looks like bright-red bumpy tissue with irregular surface on cervical surface around os – benign and more friable. It is common with women taking birth control. It can change in size, shape or disappear over time.

Sample the transformation zone (squamocolumnar junction) when performing pap. Border of brighter red ectropion and smother surface of cervix – area where abnormal cells are more likely to grow

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UTERINE FIBROIDS ➢

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Uterine fibroids (uterine leiomyoma or myoma) can enlarge the uterus. Symptoms include heavy bleeding (menorrhagia), pelvic pain or cramping and bleeding between periods.

Usually benign but can be malignant and cause uterine cancer (leiomyosarcoma)

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MENSTRUAL CYCLE ➢

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Follicular Phase (Days 1 to 14) – estrogen is the predominant hormone – stimulates development and growth of endometrial lining. FSH from anterior pituitary stimulates the follicles into producing estrogen Midcycle (Day 14): Ovulatory Phase – LH secreted by anterior pituitary gland which induces ovulation Luteal Phase (Days 14 to 28) – progesterone predominant hormone Sex 1-2 days prior to ovulation offers greatest chance of pregnancy

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RANDOM PEARLES ➢ ➢

RANDOM TESTING ➢ ➢ ➢

Tzanck smear – herpetic infections – lg. nuclei Gram stain – Neisseria gonorrhea, rarely used Whiff test – for BV ➢ KOH – fungal infections

Pap smears start at age 21 every 3 years until 29 Age 30 – pap with HPV every 5 years otherwise every 3 years Stop screening age 65 if negative hx for 15-20 yrs.

Hysterectomy with removal of cervix not due to cancer – can stop screening Specimen is satisfactory if both squamous epithelial cells and endocervical cells are present Atypical Squamous Cells of Undetermined Significance (ASC-US) o <20 yrs. repeat 1 year o 21-24 – repeat pap in 1 year o 25-29 – reflex HPV and pap in 1 year o 30+ if HPV + colposcopy, if HPV – repeat cotesting in 3 years Atypical Glandular Cells – (endometrial cells) premalignant or malignancy – endometrial biopsy Low-Grade Squamous Intraepithelial Lesions (LSIL) o 21-24 – repeat pap in 1 year o 25-29 – colposcopy with cervical biopsy o 30+ if HPV + colposcopy with cervical biopsy, if HPV – repeat in 12 months or colposcopy High-Grade Squamous Intraepithelial Lesions (HSIL) o 21-24 – colposcopy with cervical biopsy o 25+ refer for immediate excisional treatment (LEEP) or cervical conization HPV 16 and 18 cause 70% cervical cancer Vaccinate with Gardasil

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During puberty it is common for both girls and boys to have asymmetrical breasts, gynecomastia Palpable ovary after menopause – intravaginal ultrasound and rule out ovarian cancer Primary Amenorrhea - Lack of menses by age 15 w/ secondary sexual characteristics, Refer to OB – secondary to pituitary, hypothalamus etc.

WOMEN’S HEALTH

ORAL CONTRACEPTIVES ➢

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Combined oral contraceptives o Monophasic pills (Loestrin FE) – 21 active pills; placebo (iron) last 7d o Biphasic (Ortho-Novum) – two progesterone doses o Triphasic (Ortho tri-cyclin) - 21 active pills; placebo last 7d. Hormones weekly. 3 varies.

Good for acne o Extended Cycle (Seasonale) – 84 days active pill w/ 7 free days. 4 periods per yr. – breakthrough bleeding o Ethinyl Estradiol/Drospirenone (Yaz) drospirenone as progesterin; great for acne, PCOS, hirsutism, PMDD. High risk for DT/hyperkalemia. Must check K+ levels if on ACEI/ARB/K+ sparing diuretic - ↑ risk blood clots, CVA, CAD o Low dose pills contain 20 to 25 mcg of ethinyl estradiol Progestin-Only o Safe for breastfeeding, “minipill” o Take pill at same time each day o If taken late > 3 hours or miss dose, use condoms o Micronor – 28 days of progestin. Start taking on day 1 of menstrual cycle New prescriptions o Can be started after ruling out pregnancy o “Quick Start” – start on day prescribed o “Sunday Start” – first pill on first Sunday after period – will avoid periods on weekends o “Day One Start” – first pill on first day of menstrual cycle (provides best protection) o Follow-up in 2-3 months to check BP, side effects Advantages (After 5 years of use) o ↓ ovarian and endometrial cancer o ↓ Dysmenorrhea and cramps ↓ prostaglandins o ↓ endometriosis o ↓ acne and hirsutism (↓ androgen) o ↓ ovarian cyst (suppress ovulation) o ↓ heavy/irregular periods thus decreasing IDA

OTHER METHODS ➢

ORAL CONTRACEPTIVE CONTRAINDICATIONS ▪ ▪

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Absolute contraindications “My CUPLETS” o Migraines with focal neurological aura or >35 migraines without aura o CAD/CVA o Undiagnosed genital bleeding o Pregnant o Liver disease or tumor o Estrogen-dependent tumor o Thrombus/emboli – factor V Leiden o Smoker 35 or older Relative contraindications o Migraines 35+ o Smoker < 35 o Fracture/cast on lower extremity o Hypertension

ORAL CONTRACEPTIVE PROBLEMS ➢ ➢

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Unscheduled bleeding (spotting) Menstrual cramps o Mefenamic acid (Ponstel), Aleve, Advil, Anaprox Menorrhagia – heavy bleeding Missing pills o Missed 1 day – take 2 now and continue o Missed 2 days – take 2 pills for 2 days and finish pack (use condoms for current cycle) Drug interactions – anticonvulsants, antifungals, St. John’s wort, PCN, Tetracyclines, Rifampin Thromboembolic Warning signs: ACHES o Abdominal pain o Chest pain o Headaches o Eye problems (vision changes) o Severe leg pain

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IUD – risk for infection, perforation, heavy bleeding o ParaGard – copper-bearing; effective 10yrs o Mirena – levonorgestrel hormone; effective 5 yrs. little more effective than Paragard (Skyla) - smaller Depo-Provera (6% failure rate) – injections q3 month, start within 5 days of cycle. Recommend calcium with vitamin D and weight-bearing exercise. Avoid >2 years. Risk for osteopenia/porosis. Avoid if anorexic/bulimic.

May delay return of fertility – do not use if wish to become pregnant in 12 months. Does not interact with Dilantin Diaphragm w/ gel (13% failure rate) – after insertion, the cervix should be smoothly covered. Leave in for 6-8h. Add spermicide w/ every act of intercourse. Cervical cap can be work for up to 72h - ↑risk UTI and TSS Condoms (18% failure rate) NuvaRing (9% failure rate) leave inside for 3weeks Patch (9% failure rate)- risk of VTE Implants (<1% failure rate) – may take 1yr to ovulate after removal, weight gain. Norplant good for 5yr, Nexplanon 3yr

EMERGENCY CONTRACEPTION ▪ ▪ ▪ ▪ ▪

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r/o pregnancy effective up to 72h after unprotected sex most effect within first 24h inhibits ovulation, slows sperm and ovum transport Plan B – progesterone only (89% effective): take 1st dose now, 2nd dose 12h later. If vomits tablet within 1 hour – repeat dose Ulipristal – inhibits embryo transplantationapproved for up to 5 days after intercourse Return if no menses w/in 3 weeks

WOMEN’S HEALTH

Name

Cause

Breast mass/CA

Paget’s disease of breast (Ductal carcinoma in Situ)

Ectopic pregnancy

Osteoporosis

Middle-age or older female with painless mass feels hard and irregular. Mass attached to skin and tissue (immobile) RUQ of breast most common location (tail of spence). Skin changes: dimpling, retraction, peau d’orange “orange peel”, blood discharge, nipple displacement Older female c/o chronic scaly red-colored rash, like eczema, on nipple that does not heal; itching, skin lesion slowly gets larger and includes crusting, ulceration and/or bleeding. Spreads to areola

Screening – ACS age 45 then yearly; USPSTF age 50 then every 2 years < 30 start with ultrasound Diagnostic Mammogram Breast biopsy

Treatments

Concerns

Refer to surgeon

Screening: BRCA standardized questionnaire such as FHS-7 (if BRCA gene positive – consider referral for counseling)

Aggressive form of CA More common in African American

5 most common CA in women

Vague symptoms: abdominal bloating, discomfort, low-back pain, pelvic pain, urinary frequency, constipation. usually metastasized by diagnosis

BRCA 1/BRCA 2 screening starts at age 30

Risk factors: family hx, BRCA, endometriosis, >55, early menstruation, nulliparous, obesity, late menopause, infertility,

6-8 weeks after LMP

Sexually active, amenorrhoeic or light to scant bleeding, one sided lower abdominal/pelvic pain w/ cramping worsening when supine or with jarring. May refer to right shoulder, hx PID, tubal ligation, or previous ectopic

Quantitative HCG – should double 24-72 hours

Leading cause death 1st trimester of pregnancy

th

Bilateral breast tenderness and lumps up to 2weeks prior to menses, resolving w/ menses. No masses, skin changes, nipple discharge, or nodes on physical exam

Fibrocystic disease

Polycystic Ovarian Syndrome (PCOS)

Diagnostics

Acute onset red, swollen, warm area in breast of younger women. Mimics mastitis. No distinct lump. Acute onset, skin may be pitted or appear bruised.

Inflammatory breast cancer

Ovarian cancer

Signs/Symptoms

Hormonal abnormality, infertility, excessive androgen production, insulin resistance

Loss of bone density from estrogen def.

Presents teenage years; hirsutism, acne, oligomenorrhea, amenorrhea, dark hair on face, cheek, beard areas, acanthosis nigricans, mood/mental health problems Rotterdam Criteria (2 of 3): Oligomenorrhea, hyperandrogenism and cystic ovaries

“Skinny white woman who smokes and drinks” – Affects women and men Common fx sites include femur, forearm, vertebrae; ↑ risk with chronic steroid use, hx of anorexia or bulimia, long term PPI use, gastric bypass, celiac disease, hyperthyroidism, ankylosing spondylitis, Caucasian and Asian women. Lifestyle risk factors - ↓ Calcium, vitamin D, inadequate physical activity, alcohol consumption (3+ per day), ↑ caffeine, smoking

Avoid caffeine Vitamin E and evening primrose capsules daily. Wear bras with good support Transvag. ultrasound ↑ serum testosterone, DHEA, androstenedione, FSH is normal or low, FBS and OGTT are abnormal;

DXA scan: T-score < -2.5 (Osteopenia: -1.0 to -2.4) Repeat DXA in 1-2 yrs. if on meds otherwise in 2-5 yrs.

Low-dose oral contraceptives, spironolactone to control hirsutism, Provera 5-10mg daily for 10-14 days (repeat every 1-2 months), metformin to induce menses, weight loss

↑ Risk for DM2, hyperlipidemia, metabolic syndrome, endometrial hyperplasia, obesity, OSA, CAD, breast CA

Weight-bearing exercises (yoga, calcium w/ Vit D (1200/800mg), Bisphosphonates: 1st line ↑ BMD and inhibits bone reabsorption (potent esophageal irritant, take with full glass of water while sitting or standing and do not lay down for 30 minutes) Fosamax (alendronate), Actonel (risedronate), Selective Estrogen Receptor Modulator – block estrogen receptors. Good for postmenopausal women with osteoporosis who also need breast cancer prophylaxis. ↑ risk DVT, endometrial cancer, strokes and PE. Evista (raloxifene) after menopause. Parathyroid hormone (PTH) Analog – Forteo; Miacalcin and Calcitriol – weak compared to bisphosphonate.

Low calcium diet and monitor for hypercalcemia, hypercalciuria and renal insufficiency.

Long term bisphosphate tx has been associated with atypical fx. – give for 5 years and then take break.

Use of calcitonin has ↑ risk of malignancy

WOMEN’S HEALTH

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Bacterial Vaginosis (BV)

Overgrowth of anaerobic bacteria in vagina

Thin, homogenous, white, gray, copious milk-like discharge. Unpleasant “fish-like” odor worse after intercourse. Exam shows light gray discharge coating on vaginal walls. – does not cause inflammation

Wet smear: clue cells, few WBC; Whiff test – KOH applied to sample – smells fishy Alkaline vaginal pH >4.5

Metronidazole (Flagyl) BID x 7 days, Clindamycin cream, Not STD, no partner treatment needed Abstain from sex until treatment complete

Clue cell = mature squamous epithelial cell with numerous bacteria noted on cell borders

-azole antifungal, oral fluconazole (Diflucan), or vaginal miconazole (Monistat), Clotrimazole (Gyne-Lotrimin), Terconazole (Terazol-3) cream; If patient on antibiotic daily yogurt or lactobacillus pills; complicated case butoconazole

↑ Risk with HIV, those on antibiotics, diabetics

Candida Vaginitis

Candida albicans yeast in vulva/vagina

White curdy cottage cheese-like vaginal discharge c/o severe pruritus, swelling and redness.

Wet smear – pseudohyphae and spores, budding yeast w/ large # WBC

Atrophic Vaginitis

Estrogen deficiency

Vaginal dryness, itching, pain w intercourse. less rugae, pale color, may bleed on physical exam

Pap smear shows atrophic changes Elevated FSH/LH pH > 5.0

topical estrogen cream is symptomatic or recurrent UTI (oral estrogen as solo intervention is likely inadequate) Osphena (non-estrogen)

Dysmenorrhea

Excessive prostaglandins Most common GYN problem

Primary – pain improving w/ menses, N/V, diarrhea, back pain, starts as teen & improves w/ age and NSAIDs Secondary – after 35yo, abnormal bleeding, non-midline pain worsens w/ time (most commonly as endometriosis) – pain with intercourse

Good history, physical exam esp. pelvic, check STDs, fibroids,

NSAIDs; if secondary treat cause; exercise, heat to area.

Oral contraceptives

Vaginal bleeding postmenopause – endometrial biopsy for CA Structural

Post-menopausal bleeding > 12 months since LMP – refer to OBGYN r/o cancer PALM-COEIN

Abnormal Uterine Bleeding (AUB)

Menopause

Polyps > 30 years Adenomyosis > 30 Leiomyoma/Fibroids > 30 Malignancy/Hyperplasia >40

No naturally occurring menstrual period for 12 months

Hot flashes, night sweats, symptoms typically occur the week before menses. Estrogen receptors are found in highest concentration in the vagina

Non-Structural

Coagulopathy any age Ovulatory Dysfunction any age Endometrial Disorder any age Iatrogenic Medications any age Not classified

↑ LH & FSH ↓ testosterone ↓ estradiol ↓ progesterone

Hormonal Therapy – contains ¼ or less amount estrogen as COC. May preserve bone density, but contributes to endometrial, breast cancer and CAD; use lowest dose possible, if hysterectomy – add progestin component is to minimize endometrial hyperplasia. Estradiol 1mg provides relief in 4 weeks vs. low dose 8-12 weeks. Low dose is better tolerated Estrogen receptor modulator therapy: Evista – osteoporosis risk is reduced Other options: venlafaxine, sertraline, gabapentin, paroxetine Phytoestrogens include red clover, ginseng, black cohosh, yam, and soy products High dose vitamin E (800 IU)

Perimenopause 40-45

PREGNANCY

PREGNANCY ➢ ➢

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Zygote → Blastocyte → Embryo → fetus Naegele’s rule: o Subtract 3 months from first day of LMP, add 7 days = 40 weeks (280 days) 1st trimester ultrasound – crown-rump measurement (with 7-day error) 2nd trimester ultrasound – using multiple fetal measurements (with 10-14-day error) Uterine size, etc.: o Nongravid – lemon o 8 weeks – orange o 10 weeks – baseball (? Doppler heart) o 12 weeks – above symphysis pubis ▪ grapefruit (FHT doppler) o 16 weeks – between symphysis pubis and umbilicus o 16-18 weeks – quickening (feeling baby move) o 20 weeks – at umbilicus (FHT stethoscope) o 20-36 weeks – about 1 cm about symphysis pubis +/- 1 cm o At term – fundus height dropped If uterus is smaller than expected (IUGR)

SIGNS OF PREGNANCY ➢

PREGNANCY

NUTRITION

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Additional 300 kcal/d Lactation 500 kcal/d Calcium 1000-1500 mg/d Folic acid 0.4-1 mg/d (green leafy veg, cereal)

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Weight Gain: BMI Underweight Normal weight Overweight Obese ➢ ➢ ➢ ➢ ➢ ➢ ➢

<18.5 18.5 – 24.9 25.0 – 29.9 >30

Total Weight Gain 28 – 40 25 – 35 15 – 25 11 – 20

Twins: ↑ weight gain (37-54lbs) After delivery – loss of 20-30lbs in first few weeks Avoid soft cheese, uncooked meats, raw milk Do not eat raw shellfish or raw oysters (Vibrio vulnifucus infection) Be careful with cold cuts, uncooked hot dogs and deli meats (Liesteria monocytogenes) Regular coffee 8 oz.

Most weight is gained in 3rd trimester (about 1-2 lbs. per week)

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RISK FOR ECTOPIC ➢ Hx of salpingitis ➢ Prior ectopic pregnancy ➢ Hx of tubal surgery ➢ Assisted reproduction ➢ Hx of infertility ➢ Cigarette smoking ➢ Progestin use ➢ Current IUD use ➢ Previous cervicitis or PID ➢ Tubal ligation failure Consider if hcg > 1500 and us fails to show pregnancy Methotrexate or surgical

Positive signs o Palpation of fetus by health care provider o Ultrasound and visualization of fetus o Fetal Heart Tones auscultated ▪ 10-12 weeks doppler ▪ 20+ fetoscope/stethoscope Probable signs o Goodell’s sign (4 weeks) – cervical softening o Chadwick’s sign (6-8 weeks) – blue color o cervix and vagina o Hegar’s sign (6-8 weeks) softening uterine isthmus o Enlarged uterus o Ballottement – when fetus is pushed, it can be felt to bounce back by tapping the palpating fingers inside vagina o Urine HCG (because also can present in molar pregnancy and ovarian cancer) Presumptive signs o Amenorrhea o N/V o Breast changes o Fatigue o Urinary frequency o Slight increase in body temperature o “Quickening” – mother feels baby’s movements for 1st time (16 weeks)

ASYMPTOMATIC BACTERIURIA ➢ ➢ ➢ ➢ ➢ ➢

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Always treat (asymptomatic 3, symptomatic 7) Macrobid BID x 5-7 days Augmentin BID 3-7 days Amoxicillin BID 3-7 days Cephalexin BID 3-7 days Avoid nitrofurantoin and sulfa drugs near term, during labor and during delivery – contraindicated in neonates ↑ hyperbilirubinemia → kernicterus UTI in pregnancy is complicated UTI

RANDOM PEARLES ➢ ➢

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Zika – cleft palate, highest risk in 1st trimester Schedule of visits o Every 4 weeks until 28 weeks o Every 2 weeks until 36 weeks o Every week until delivery Drugs can pass placental barrier <500 daltons, unable to pass at >1000 daltons Pregnancy with asthma – bronchospasm in 36-40 wk.

PREGNANCY

LABS ➢ ➢ ➢ ➢

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UA every visit Alkaline phosphatase always ↑ due to bones Leukocytosis with neutrophilia is normal Alpha-Fetoprotein (AFP) – check 16 -20 weeks o Low – order triple screen to evaluate for Down syndrome o High – r/o neural tube defects or multiple gestation ↑ sono Triple Screen Test (AFP, beta HCG, estriol serum) Quad – triple + inhibin A (hormone by placenta) o Down syndrome Amniocentesis –gold standard for genetic disorder is fetal chromosomes/DNA (spontaneous fetal loss 1-400) Tay-Sachs disease (neurologic, common Jews) Cystic Fibrosis (white) Sickle cell trait (blacks) 1st prenatal – document HCG o Pap, GC/chlamydia o Rubella, varicella, rubeola o Syphilis, HIV, HBsAg, consider HCV o CBC, blood type, antibody screen o TSH if being treated 16-20 weeks o Quad marker/screen 24-28 weeks o Screen for gestational DM 28-32 weeks o STI o RhoGAM if indicated (Rh -) 32-36 weeks o Fetal presentation o Kick counts 35-37 weeks o Group B strep culture o Positive – pen G 5 million IV followed by 2.5-3 million Q4 until delivery 40-42 week o Vaginal exam to assess cervical ripeness

DRUGS IN PREGNANCY PHYSIOLOGICAL CHANGES ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

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Heart is shifted anteriorly and towards left Heartrate ↑ 15-20 BPM Heart sounds are louder, S3 is common, splitting of S2 may be heard Systolic ejection murmur (II/IV) heard over pulmonary and tricuspid area CO ↑ 30-50% (↑ preload), ↓ SVR and BP (↓ afterload) Plasma volume ↑ 50% Physiological anemia Uterus compresses vena cava (orthostatic HTN) Hypercoagulable state Basal rales that disappear with coughing No change in FEV1 but ↓ total lung capacity Constipation, heartburn ↑ melanocyte-stimulating hormone causing linea nigra (dark line from down abdomen) and nipples and areola darken Chloasma (melasma) – blotchy hyperpigmentation on forehead, cheeks, nose and upper lip – more common in dark skin, due to ↑ estrogen level Striae gravidarum Telogen effluvium (hair loss) – during postpartum Kidney size ↑ - GFR ↑ due to ↑CO and renal blood flow Nasal congestion, epistasis due to ↑ blood flow Varicose veins Peripheral edema

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RANDOM PEARLES ➢ ➢ ➢ ➢

OBSTETRIC HISTORY ➢ ➢ ➢ ➢ ➢

Gravida Term Preterm Abortion Living

Category A – o Vitamin A, Levothyroxine Category B – SAFE o PCN, Cephalosporin, macrolides, acetaminophen, Pulmicort, Maalox, Colace, methyldopa (check LFT – discontinue with jaundice, abnormal LFT or unexplained fever), CCB (Procardia), BB (labetalol), insulin Category C – Probably SAFE o Sulfa in 3rd trimester, Clarithromycin, NSAIDs (premature closure of ductus) Category D – May NOT be safe o ACE/ARB, quinolone, tetracycline, Tegretol, Depakote, fluoxetine, paroxetine Category X – NOT Safe o Accutane, Thalidomide, statins, Proscar, misoprostol, Evista Teratogens – alcohol (FAS), aminoglycosides (deaf), cigarettes (IUGR), cocaine (CVA), isotretinoin, lithium (cardiac defects), gestational diabetes (LGA, neural tube defects)

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Cat litter or raw/undercooked meat can cause toxoplasmosis Smoking (IUGR) and alcohol are contraindicated Do not use hot tubs, saunas or expose oneself to excessive heat Progesterone, CCBs relaxes esophageal sphincter and contributes to heartburn Uterine involution – uterine contractions for 2-3 days after birth. Soft boggy uterus with heavy vaginal bleeding is atony (inadequate contraction). Involution takes about 6 weeks.

Breastfeeding speeds this up.

Edwards trisomy 18

PREGNANCY

Name

Signs/Symptoms

Diagnostics

Treatments

Concerns

Placental Abruption (Abruptio Placentae)

Late third trimester pregnancy with sudden onset vaginal bleeding accompanied by contracted uterus, painful. Hard abdomen, rigid uterus. Up to 20% do not have vaginal bleeding

CBC, PT/PTT, Type and Cross, Rh, sono

Deliver fetus; severe case can cause hemorrhage

↑ Risk with HTN, preeclampsia/eclampsia, cocaine use or hx of abruptio placentae

Placenta Previa

Multipara late 2nd to 3rd trimester with new onset painless bleeding worsened by intercourse. Soft, nontender uterus.

Bedrest. Mag sulfate for cramping. If mild, uterus will reimplant. No vaginal or rectal stimulation. If cervical dilation or hemorrhaging, fetus is delivered via Csection

↑ risk hx., C-section, multipara, older age, smoking, fibroids, cocaine

Preeclampsia

Unknown – risk factors: primigravida, multipara, > 35, obesity, prior hx., HTN or kidney disease

Primigravida in late 3rd trimester (>34 weeks); sudden onset recurrent headaches, visual abnormalities (blurred vision, scotomas) and pitting edema. Edema easity seen on face/eyes and fingers. Sudden rapid weight gain in 1-2 days.

New onset RUQ pain, BP > 140/90 with urine protein 1+, oliguria. N/V are worrisome for encephalopathy. Can start at 20 weeks. If seizures, Eclampsia.

Triad: HTN, proteinuria and edema > 20 weeks BP > 140/90 Proteinuria 0.3 gram in 24 hours Edema face, eyes, hands

Delivery – can occur up to 4 weeks after delivery

HTN before 20 weeks is HTN – may be able to get off meds during 1st and 2nd trimester

HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets)

Serious but rare complication of preeclampsia/eclampsia

Signs and symptoms of preeclampsia that present suddenly

↑AST, ALT, lactate dehyrogenase Total Bili > 1.2 Platelets <100,000 ↓ H/H

Rh-negative mother with Rh-positive fetus

Maternal immune system produces antibodies against Rh-positive blood if not given RhoGAM. Give for all pregnancies of Rh-negative mothers – even if they terminate in miscarriage, abortion, ectopic etc.

Rh-incompatibility

Gestational Diabetes

Cause

Associated with higher rates of neural tube defects, congenital heart disease, birth trauma (shoulder dystocia), preeclampsia, hydramnios, macrosomia, fetal organomegaly and neonatal hypoglycemia. Risk factors – hx, obesity, Asian, Native American, Pacific islander, black, Hispanic, infant > 9lbs, older than 35

Coombs: detects Rh antibodies (indirect) and infant (direct)

Screen at first visit if high risk otherwise screen at 24-28 weeks Diabetes in 1st trimester = Type 2 diabetes Test 6-12 weeks postpartum and every 3 years afterwards

Multipara > 25

RhoGAM (anti-D immune globulin) made from pooled IgG antibodies. If not given, this will result in fetal hemolysis in future pregnancies. ↓ risk by destroying fetal Rh+ RBC that have crossed placenta 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 Two Step Method – 50 g OGTT (not fast) Check plasma glucose at 1 hour (if > 140 – order 100 g OGTT – Fasting (8 hrs.) > 95 1 hour > 180 2 hours > 155 3 hours > 140 Glycemic targets – Preprandial 95 or less 1 hour < 140 2 hours < 120 A1C goal: 6-6.5% Lifestyle measures → insulin, glyburide, metformin

Higher risk for Type 2 diabetes

SEXUALLY TRANSMITTED DISEASES

Name

HIV

Cause

HIV-1 most common strain in US Attacks CD4 Tlymphocytes

Signs/Symptoms

Hairy leukoplakia of tongue (caused by EpsteinBarr virus of tongue), recurrent candidiasis, thrush, fever, weight loss, diarrhea, cough, shortness of breath, Kaposi’s sarcoma; symptoms develop within 2-4 weeks

It can take 3-12 weeks for HIV antibody test to detect HIV

Chlamydia trachomatis

Atypical bacteria Incubation 7-14 days

Asymptomatic. Most common STD in US; Samples from urine, cervix, urethra, fallopian tubes, oral and rectal sites. Can occur in endometrium

Neisseria gonorrhoeae

Gm- diplococci bacteria Incubation 1-5 days

Purulent green-colored vaginal/penile discharge; exam shows discharge on cervix which may bleed.

May be asymptomatic, Cervicitis, urethritis, pharyngitis, Bartholin gland abscess, salpingitis, epididymitis/prostatitis

Fitz-Hughes-Curtis Syndrome (Perihepatitis)

ELISA – screening Western blot – Confirmatory for HIV antibodies HIV PCR if both + Normal CD4 count 500-1500

Petechial or pustular skin lesions of hands/soles; swollen, red, tender joints in one large joint (knee). May have s/s STD, pharyngitis w/ green purulent throat exudates not responding to antibiotics

Disseminated Gonococcal disease

Syphilis

Diagnostics

Treponema pallidum (spirochete) 2-4-week incubation

Chlamydial and/or gonococcal infection of liver capsule causing scarring

Primary – painless chancre with lymphadenopathy that last 3 weeks. Heals spontaneously (Chancre should start healing 3-7 days after injection if treated) Secondary – ***most contagious nonpruritic skin rash, involving palms and soles, mucous membranes. Fever, lymphadenopathy, sore throat, patchy hair loss, headaches, weight loss, condyloma lata Latent – variable Tertiary – neurosyphilis, gumma, aneurysms, valve damage

Symptoms of PID complaining of RUQ abdominal pain and tenderness on palpation

Treatments

Prophylaxis if CD4 <200: Bactrim daily; If allergic: Dapsone, atovaquone, aerosolized pentamidine Pregnancy – start Zidovudine (AZT) ASAP; Newborns start within 6-12 hours of delivery Best sign of treatment is ↓ viral load Pneumocystis jirovecii causes most deaths in people with HIV Tenofovir disoproxil fumarate – UA every 6 months - nephrotoxic; Zidovudine – CBC (bone marrow suppression) If exposed PEP – start ASAP PrEP reduces HIV transmission 90%

Concerns

AIDS = CD4 < 200 Toxoplasma gondii (protozoa) CD4<100 Bactrim daily; headaches, blurred vision, confusion Avoid: cat litter, uncooked pork/beef, bird stool, turtles/amphibians, gardening

Refer – Ceftriaxone 1-gram IM or IV every 24 hours

NAAT test for pharynx/rectal samples; GenProbe for cervix/urethra Friable cervix with yellow discharge NAAT test for pharynx/rectal samples; GenProbe for cervix/urethra

Azithromycin 1G, Doxycycline 100mg x7d Treat sexual partners – Azithromycin 1G Test of cure only for pregnant women 3w after completion with Azith or Amox.

Complicated: Rocephin 250mg IM + doxycycline PO BID x 14 days with or without Flagyl PO BID x 14 days

Leads to PID (PID has + chandelier’s test) Most common < 25

Ceftriaxone 250mg IM (Rocephin) + Azithromycin 1-gram PO (if allergic Gemifloxacin 320mg PO + azithromycin 1gram PO)

IF GC + always co-treat for chlamydia even if test negative Incubation 1-5d

RPR or VDRL for screening (nontreponemal test) confirm w/ FTA-ABS (treponemal test)

Primary: Benzathine PCN G 2.4mil x 1dose or doxycycline for allergy. If latent syphilis administer weekly x 3 weeks (Genital) Recheck RPR 6-12 months Treat partners and test for HIV/STDs Refer to infectious disease if latent or tertiary

Liver function normal

Treat as complicated gonorrheal/chlamydial infection Rocephin 250mg IM + doxycycline PO BID x 14 days with or without Flagyl PO BID x 14 days

Risk: men with men, HIV infection. most contagious during secondary stage False positive RPR: pregnancy, Lyme disease, autoimmune disease, chronic or acute disease Jarisch-Herxheimer Reaction – acute febrile reaction during first 24 hours of treatment. Acute onset fever, chills, HA, myalgias. Supportive treatment.

SEXUALLY TRANSMITTED DISEASES

Name

Cause

Signs/Symptoms

Reiter’s syndrome

Immune mediated reaction secondary to infection with bacteria (chlamydia) that resolves

Mostly in males. Presents w/ history of chlamydia c/o red, swollen joints that come and go (migratory arthritis) “I can’t see (conjunctivitis), pee (urethritis), or climb up a tree (migratory arthritis”

Condyloma Acuminata; Verruca Vulgaris (genital warts)

Diagnostics

Treatments

Supportive - NSAIDs

Imiquimod (Aldara) 5% cream – leave on 6-10h 3x a week; Podofilox (Condylox) cream 2x day x 3 days – hold for 4 days and repeat, if pregnant liquid nitrogen, bichloracetic or trichloroacetic acid wash in office

HPV (malignancy 16, 18)

Soft flesh-colored pedunculated, flat, or popular growths.

Appear as white-colored skin on cervical surface after swabbing w/ acetic acid

Herpes Simplex 1&2

HSV-1 oral mucosa HSV-2 genital

Prodromal itching, burning and tingling at site. Sudden onset groups of small vesicles on erythemic base, easily ruptures and painful; can last 2-4 weeks Can travel oral, genital, and intact skin via asymptomatic transmission

Herpes viral culture or RPR assay Tzanck smear (old test)

Acyclovir (Zovirax), Famciclovir (Famvir), Valacyclovir (Valtrex) Episodic: Famciclovir/Zovirax Suppressive treatment: Acyclovir/Famciclovir Suppressive therapy decreased reoccurrences by 70-80%

Chancroid

Gm – Haemophilus ducreyi

Found at site in inoculation with vesicular-form to pustular form lesion creating a painful, soft ulcer with necrotic base. Multiple lesions are usually found

Culture for H. ducreyi (sensitivity <80%)

Azithromycin, ciprofloxacin and ceftriaxone; Lifestyle changes: condoms, limit partners, STI/HIV testing, Hep. vaccines

Lymphogranuloma Venereum

C. Trachomatis

Symptoms occur 1-4 weeks after contact; vesicular or ulcerative lesion on external genitalia progressing to inguinal lymphadenitis or buboes which fuse, then drain

PCR assay

Doxycycline and erythromycin Lifestyle changes: limit partners, STI testing, Hep vaccines

Pelvic inflammatory disease

N. gonorrhoeae, C. trachomatis, bacteroides, Enterobacteriaceae, streptococci

Irritating voiding symptoms, fever, abdominal pain, cervical motion tenderness, adnexal tenderness, vaginal discharge.

Trichomoniasis

Trichomonas Vaginalis Protozoan parasite w/ flagella

Dysuria, bubbly itching, vulvovaginal irritation, yellow-green vaginal discharge, occasionally frothy.

Concerns

Pap smear, colposcopy

Ceftriaxone 250mg PO plus doxycycline 100 mg BID x 14 days with or without metronidazole 500mg PO BID x 14 days Exam: “strawberry” cervix w/ some bleeding Wet smear: motile protozoa flagella and large # WBC

Prevent with Gardasil – give at age 11 and 12 carcinogenic

r/o syphilis and HSV Even when asymptomatic, virus sheds 10% of the time

↑ risk for ectopic pregnancy and/or infertility

Metronidazole (Flagyl) 2gram PO or tinidazole 2gram PO or 500mg PO BID x 7 days. Abstain from alcohol use until treatment complete. Treat sexual partner; 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

RANDOM PEARLES

PROSTATE GLAND Normal prostate (See A below)

Firm, smooth, nontender

Acute prostatitis

Tender, boggy, indurated

BPH (See B-F below)

firm, smooth symmetrically enlarged Asymmetric, Nodular, hard, nontender

Prostate cancer

Produces PSA

Firm as pressing in on tip of your nose Firm as pressing in over your cheekbone Firm as pressing in on tip of your nose Usually malignant lesions not palpable until disease is advanced

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Sperm produced in seminiferous tubules of testes Sperm require about 3 months to mature (stored in epididymis until mature) Production of testosterone is stimulated by release of luteinizing hormone Spermatogenesis is stimulated by testosterone and follicle-stimulating hormone Transillumination for evaluating testicular swelling, mass, bleeding or cryptorchidism o Hydrocele will transilluminate o Tumor and varicocele (bag of worms) will not transilluminate Postrenal azotemia – can be due to prolonged urinary obstruction leading to hydronephrosis and compromised renal failure Only scrotal edema and no pain – assess for generalized weakness and refer to urology

MEN’S HEALTH

Name

Cause

Signs/Symptoms

Priapism

Sickle cell, drugs for ED, cocaine, quadriplegia

Prolonged and painful erection for several hours

Teen to young adult c/o nodule, sensation of heaviness, testicle larger than other. One testicle heavier, may palpate hard fixed nodule. Usually asymptomatic until metastasis

Testicular cancer

Prostate Cancer

2nd most common cancer in men

Painless, hard fixed nodule, asymmetrical enlargement on prostate gland on older male.

New onset ED low back pain, rectal area.

Discomfort with voiding, weaker stream, nocturia.

May be asymptomatic. ↑ PSA with prostate infection, ejaculation, cycling, enlarged prostate gland

Torsion of Appendix Testis (blue dot sign)

Infarction/necrosis of appendix testis NOT Testicular Torsion

Diagnostics

Concerns

Surgical emergency

Ultrasound for solid mass Gold standard: testicular biopsy Asymmetric, hard, nodular prostate. PSA > 4.0 Biopsy of prostatic tissue PSA looks good when taking Flomax; Prostate shrinks (temporarily) while on Proscar so PSA must be doubled

School age; complains abrupt onset blue-colored mass on testicular surface resembling “blue-dot”.

Blue dot caused by infarction and necrosis

Hernia

Treatments

Refer to urology for biopsy and management

Refer to urologist PSA > 4.0 for all or PSA > 2.5 if high risk Antiandrogens: Finasteride (Proscar) Hormone blockers (Lupron) USPSTF does not recommend screening asymptomatic DRE/PSA

Refer to ED

Inguinal – on exam

Rectal exam – firm, smooth symmetrically enlarged prostate gland

Average age > 71 Risk factors: African American, Jamaicans, obesity.

Proscar teratogenic (don’t touch w/ bare hands – affects male fetus) Appendix teste is round, small pedunculated polyp-like structure attached to testicular surface

Surgical repair

Lifestyle changes: ↓ caffeine, alcohol, fluids before bed, avoid diuretics Alpha-adrenergic antagonist - Terazosin (Hytrin), Tamsulosin (Flomax) – monitor for orthostatic hypotension (take at bedtime)- Finasteride; Refer to urology; Avoid: antihistamines, decongestants, caffeine; amitriptyline. Herb: saw palmetto may improve symptoms

BPH

Non-cancerous enlargement of prostate gland

LUTS – lower urinary tract symptoms. Nocturia, difficulty starting stream, weakened stream, dribbling, feelings of incomplete emptying, urinary retention Prostate size does not correlate well with severity of symptoms

Chronic Bacterial Prostatitis

Chronic > 6 weeks of infection of prostate caused most commonly

by E. coli and Proteus

Hx of acute UTI or may be asymptomatic. Several weeks suprapubic or perineal discomfort w/ irritative voiding symptoms, dysuria, nocturia, frequency

Prostate feels normal to palpation; UA normal Culture

Trimethoprim-sulfamethoxazole (Bactrim), if sensitive, give ofloxacin or levofloxacin Treat 4-6 weeks

Acute Prostatitis

Bacterial infection E. coli and Proteus or STD

Sudden onset high fever, chills w/ suprapubic and/or perineal pain; pain radiating to back or rectum w/ dysuria, frequency, nocturia and cloudy urine. “hurts when bottom hits chair or ride in car” When you had BM, did it hurt?

Enlarged, boggy (could be firm), warm and tender prostate CBC, UA, C&S

<35: ceftriaxone and doxycycline >35: ciprofloxacin or Levaquin for 6 weeks antipyretics, NSAIDs, stool softeners w/o laxative, sitz bath, hydration. Should see improvement within 2-6 days

PSA level should be doubled with Flomax and Proscar to reflect true PSA

More common in whites 15-35 yrs. Rare in African Americans.

Cryptorchidism (undescended testes) ↑ risk of cancer

Seen in 50% of men > 50 80% men > 70

Vigorous palpation of infected prostate can cause septicemia and pain

MEN’S HEALTH

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Abrupt onset extremely painful and swollen red scrotum. Frequent has N/V, affected testicle located higher and closer to body than unaffected testicle. Left side more often affected

Loss of cremasteric reflex (testicle elevated toward body with stroking inner thigh) UA Ultrasound (done in ED)

urologic emergency 6h window for survival >85% Orchiopexy to prevent recurrence

Most common between 10-20; more common with bell clapper deformity

CBC, UA, C&S, + Prehn’s sign (relief of pain with scrotal elevation) + Cremasteric reflex Check for STI

<35 -Doxycycline x 10d >35 – Ofloxacin or levofloxacin x 10d NSAIDs, scrotal support/elevation

Infertility is possible post infection due to scarring of vas deferens

Concomitant nitrates, caution alpha-blockers, recent MI, post CVA

Testicular Torsion

Spermatic cord becomes twisted

Epididymitis

Inflammation (can be infectious)

Erectile dysfunction

Vascular insufficiency (diabetes, HTN), neuropathy, medications (SSRI, BB), smoking, alcohol, hypogonadism

Inability to have an erection firm enough to perform sexual intercourse

Phosphodiesterase 5 inhibitor – take Viagra on empty stomach Viagra or Levitra – take prior to sex Cialis – take within 36 hours of sex May cause headache, flushing, dizziness, hypotension, nasal congestion, priapism

Peyronie’s disease

Inflammation

Penile pain primarily occurring during erection. palpable nodules (fibrotic plaques) and crooked penile erection May resolve spontaneously or worsen over time

Refer to urology

Balanitis

Candida infection

Inflammation of glans penis, more common in uncircumcised men, DM, or immunocompromised males OTC azole creams Treat partner

Phimosis

Edema

Foreskin cannot be pushed back from glans penis. Usually seen in neonates

Varicocele

Abnormally dilated spermatic vein

Varicose veins in scrotal sac (“Bag of worms”) – only present in standing position. New onset can signal testicular tumor or mass impeding venous drainage; may have recurrent scrotal pain

Scrotal ultrasound Treatment if causing pain, atrophy or infertility includes -surgery or percutaneous embolization Scrotal support can help

May have decreased sperm count

Hydrocele

Underlying cause may be hernia

Collection of serous fluid that causes painless scrotal swelling, easily recognized by transillumination

Scrotal ultrasound Refer to urologist

Non-communicating disappears within 1st year of life – scrotum will look like deflated balloon.

Acute or chronic swollen red scrotum that’s painful w/ unilateral testicular tenderness and discharge. Scrotum is swollen and erythematous w/ induration of the posterior epididymis, s/s UTI; most common when people sit too long

ELDERLY

DELIRIUM VS DEMENTIA DELIRIUM Sudden state of rapid changes in brain function reflected in confusion, change in cognition, activity and LOC Etiology Onset

Memory Duration Reversible Sleep disturbance

Psychomotor

Perceptual Disturbances Speech

Acute underlying cause such as acute illness Abrupt, over hours to days.

Impaired but variable recall Hours to days Usually reversible Disturbed sleep-wake cycle with hour-to-hour variability often worse as day progresses Usually a change, hyperkinetic, hypoactive or mixed. None in almost 15% Yes, including hallucinations Incoherent, confused with inappropriate words

DELIRIUM ETIOLOGY DEMENTIA Slowly developing impairment of intellectual or cognitive function that is progressive and interferes with normal functioning Variety of causes Insidious that cannot be related to a precise date, gradual change in mental status.

Memory loss, especially for recent events Months to years Chronically progressive and irreversible Disturbed sleep-wake cycle but lacks hour-tohour variability, often day-night reversal None until late in disease

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Drugs – when any medication is added, or dose adjusted. (Anticholinergics, TCA, antihistamines, antipsychotics, opioids, opiates, benzodiazepines, alcohol, etc.)

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Emotional – mood disturbances, loss Electrolyte disorder (hyponatremia)

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Low PO2 – CAP, COPD, MI, Pulmonary edema Lack of drugs

Infection – UTI, CAP ➢ Retention of urine or feces ➢

Reduced sensory input (blindness, deafness, darkness, change in surroundings)

Ictal or post ictal state ➢ Undernutrition – protein/calorie malnutrition, vitamin B12 or folate deficiency, ➢

dehydration ➢

Metabolic – diabetes, thyroid, MI

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Subdural hematoma INTERVENTION

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Assess those at greatest risk Treat underlying condition

DEMENTIA ETIOLOGY None until later in the disease In early stages

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Alzheimer-type 50-80% (loss of executive functioning) Vascular dementia - 20% (memory loss after stroke) Parkinson disease – 5% Misc. – HIV, dialysis encephalopathy, neurosyphilis, normal pressure hydrocephalus, Pick’s disease, Lewy body disease, frontotemporal dementia

CANCER IN OLDER ADULTS ➢

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Cancer with highest mortality: lung and bronchial cancer (both genders) – most common risk factor – smoking; non-small cell lung carcinoma (90%) – if presents in clinic with cough etc. CXR, then CT scan, gold standard is positive lung biopsy. Baseline labs include CBC, FOBT, chemistry panel, UA. Refer to pulmonary for bronchoscopy and tumor biopsy. USPSTF recommends annual screening with CT (age 55-80) with 30 pack yr. smoking hx and currently smoke or quit within past 15 yrs.

Cancer with 2nd highest mortality: colorectal cancer – about 20% have distant metastases at time of presentation – risk factors – advancing age, inflammatory bowel disease, or family hx of colorectal cancer, colonic polyps, lack of regular physical exercise, high-fat diet, low fiber diet, obesity. If presents with change in bowel habits, CBC, FOBT, chemistry panel, UA and refer to GI. At age 50 start with baseline colonoscopy (repeat every 10 yrs.); sigmoidoscopy every 5 yrs., Cologuard every 3 yrs. for low risk, or FOBT annually.

ELDERLY

STANDARDS FOR ALZHEIMER CARE ➢

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To slow the decline in dementia o Vitamin E 1000U BID or o Selegiline 5mg BID Mild to moderate stage disease o Cholinesterase inhibitors ▪ Donepezil (Aricept) ▪ Rivastigmine (Exelon) ▪ Galantamine (Razadyne) o Clear minor benefits More advanced dementia o N-methyl-D-aspartate receptor antagonist memantine (Namenda) Treat agitation and depression Consider non-AD related reasons for behavioral issues o Pain, infection If environmental manipulation fails o Psychotropic (risperidone)

MEDS TO AVOID IN ELDERLY

ELDERLY PEARLS ➢

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Top 3 leading cause of death > 65 o Heart disease (MI, heart failure, arrhythmia) o Cancer (lung and colorectal) o Chronic lower respiratory disease (COPD) Fasting growing age is 85+ Young old is considered 65 to 74 Any unexplained iron-deficiency anemia who is older, male or postmenopausal should be referred for colonoscopy If chemistry shows ↑ calcium or alkaline phosphatase, indicative of cancerous metastasis of bone Depression is very common in dementia Cholinesterase inhibitor side effects include nausea and diarrhea Syncope Dizziness Vertigo

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ELDER ABUSE ➢ ➢

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Presence of bruising, skin tears, lacerations and fractures that are poorly explained Presence of sexually transmitted disease, vaginal and/or rectal bleeding, bruises on breast are indicators of possible sexual abuse Malnutrition, poor hygiene, and pressure injuries Screen for abuse and financial exploitation Interview alone: o Do you feel safe where you live? o Who handles your checkbook and finances? o Who prepares your meals?

ACTIVITIES OF DAILY LIVING ➢ ➢ ➢ ➢

Ability to feed self Ability to manage bowel and bladder elimination Personal hygiene and grooming INSTRUMENTAL ACTIVITES OF DAILY LIVING o Grocery shopping o Housework o Managing finances o Using telephone o Driving a car

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Anticholinergic Effects o Tricyclic antidepressants o Overactive bladder medications o First generation antihistamines o Dry as a bone (dry mouth/eyes) o Red as a beet (flushing) o Mad as a hatter (confusion) o Hot as a hare (hyperthermia) o Can’t see (vision changes) o Can’t pee (urinary retention) o Can’t spit (dry mouth) o Can’t shit (constipation) Significant risk of orthostatic hypotension o Tricyclic antidepressants Increase in fall and fracture o Sleep medications Potential to promote fluid retention o NSAIDs Increased risk for hyponatremia o SSRI o Start elderly on SSRI and recheck in one month (esp. those taking thiazides) Use in caution with BPH, narrow-angle glaucoma and preexisting heart disease.

ASSESS FOR FALL RISK ➢

Timed Get up and Go

ELDERLY

BODY AND METABOLIC CHANGES ➢

Skin and Hair – atrophies, less elasticity due to less subdermal fat and collagen.

Fragile and slower to heal. Xerosis (dry skin) due to ↓ sebaceous and sweat gland activity (↑ risk dehydration, heat stroke). ↓ in vitamin D synthesis. Fewer melanocytes which contributes to gray hair. o Seborrheic keratoses – soft wart-like skin that appear pasted on; found mostly on back; color can range from tan, brown to black; benign

o

BODY AND METABOLIC CHANGES ➢

Eyes – presbyopia – loss of elasticity of lenses and difficulty in focusing on objects up close. Onset mid 40’s – reading glasses. Need more illumination, increased sensitivity to glare, washing out of colors. o Arcus Senilis – opaque gray to white ring in margin of cornea or on periphery of iris, develops gradually and not associates with visual changes. Caused by deposit of cholesterol and fat. If less than 40 – chest fasting lipids.

Senile Purpura – bright colored patches with well demarcated edges. o

o

Lentigines – “liver spots” tan to brown colored macules on dorsum of forearms and hands. o

➢ o

Stasis Dermatitis – due to chronic edema ➢

o

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Cataracts – cloudiness and opaque lens of eye. Gradual onset with decreased night vision. Red reflex disappears. Most common cause of blindness in developing countries.

Senile Actinic Keratosis – secondary to sun exposure with potential for malignancy (precursor to squamous cell cancer)

Nails – growth slows and become brittle, yellow and thicker with longitudinal ridges.

Mouth – hyposmia – decline in sense of smell

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Macular degeneration – loss of central field of vision. Most common cause of blindness in US. Ears – presbycusis (sensorineural hearing loss) – high frequency hearing loss.

Starts about age 50. Prevent by using ear protection when exposed to loud noise Heart – elongation and tortuosity (twisting) of arteries. Thickened intimal layer of arterioles and arteriosclerosis result in ↑ BP due to vascular resistance. Mitral and aortic valves may contain calcium deposits. o Baroreceptors are less sensitive to changes in position. Maximum heart rate decreases. ↑ risk orthostatic hypotension. S4 can be normal finding. Left ventricle hypertrophies.

Lungs – Total lung capacity remains the same. FVC and FEV1 ↓ with age.

Residual volume ↑ with age due to ↓ in lung and chest wall compliance. Chest wall becomes stiffer and diaphragm is less efficient. o Mucociliary clearance is less efficient. Response to hypoxia and hypercapnia decrease. More common to see decreased breath sounds and crackles in bases without disease (improve after asking patient to cough). ↑ AP diameter Liver – Size and mass decrease due to atrophy. Fat deposits are more common.

ALT, AST, alkaline phosphatase is not significantly changed. Metabolic clearance of drugs is slowed. LDL and cholesterol levels ↑ with age.

ELDERLY

BODY AND METABOLIC CHANGES ➢

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Renal – Size and mass decrease after age 50. At age 40, the GFR starts to decrease. Up to 30% of renal function is lost by age 70. Renal clearance of drugs is less efficient. Serum creatinine is less reliable indicator of kidney function due to ↓ muscle mass, creatine production and creatinine clearance. Kidney damage from NSAIDs is much higher and renin-angiotensin levels are lower.

Genitourinary – Residual urine ↑. Postmenopausal women urethra becomes thinner and shorts the ability of the urinary sphincter to close tightly. Urinary incontinence is 2-3 times more common in women. Erectile dysfunction affects 40% of men age 40 and 70% of men age 70.

Musculoskeletal – older adults can lose 1-3 inches of height due to thin bone loss. Compression fractures are a sign of osteoporosis. Stiffness in the morning that improves with activity is a sign of osteoarthritis (degenerative joint disease). Fat mass ↑ as muscle mass and muscle strength ↓. Bone resorption is more rapid in women than men 4:1. Fractures heal more slowly due to ↓ osteoblasts (build new bone) while osteoclast break down bone.

Gastrointestinal – receding gums and dry mouth are common. ↓ sensitivity of taste buds results in ↓ appetite. ↓ efficiency in absorbing folic acid, B12 and calcium by small intestine. Delayed gastric emptying. ↑ risk gastritis and GI damage from ↓ prostaglandin production. Constipation is more common as colon transit time is longer. Fecal incontinence is common due to drug side effects and disease. Laxative abuse is more common.

Endocrine – minor atrophy of pancreas. ↑ levels of insulin with mild peripheral insulin resistance. Changes in circadian rhythm hormonal secretions can cause changes in sleep patterns.

Sex Hormones – testes are active the entire life cycle. Less DHEA and testosterone are produced. Estrogen and progesterone production ↓ in menopause.

Immune system – older adults are less likely to present with fever. ↓ antibody response to vaccines. Immune system is less active. Cellular immunity (Tlymphocytes, macrophages and cytokines) is affected more by aging than humoral immunity (B-lymphocytes and antibody production).

Hematological – no change in RBC life span, blood volume or circulating lymphocytes. ↑ risk of thrombi and emboli ↑ platelet responsiveness. ↑ risk of iron and folate-deficiency anemia due to GI tract ↓ absorption of B12 and folate.

BODY AND METABOLIC CHANGES ➢

➢

Neurological – differences in ability to differentiate color, papillary response and decreased corneal reflex. ↓ gag reflex. Deep tendon reflex may be brisk or absent. Neurological testing may be impaired by medications, causing slower response times. Benign essential tremor is common.

Pharmacological – drug clearance is impaired by renal impairment, less efficient liver, delayed gastric emptying, ↑ gastric pH, ↓serum albumin (affects coumadin and Dilantin - ↓ dose), and higher ratio of fat to muscle. ↑ sensitivity to benzo and anticholinergic (hypnotics, TCA, antihistamine and antipsychotic).

Rate of absorption is changed. ↓ beta-2 receptor sites. ↓ ability to conserve sodium.

NEUROCOGNITIVE FINDINGS ➢ ➢ ➢ ➢

➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

Abulia: loss of motivation or desire to do task, indifference to social norms Akathisia: intense need to move due to severe feelings of restlessness Akinesia: reduce voluntary muscle movement Amnesia: memory loss, anterograde amnesia is memory loss of recent events (occurs during disease); retrograde amnesia is memory loss of events in the past (before the onset of disease) Anomia: problems recalling words or names Aphasia: difficulty using (speech) and/or understanding language; can include difficulty with speaking, comprehension and written language Apraxia: difficulty with or inability to remember learned motor skill Astereognosis: inability to recognize familiar objects placed in the palm Ataxia: difficulty coordinating voluntary movement Broca’s aphasia: ability to speak is intact but ability to comprehend language is lost Confabulation: “lying” or fabrication of events due to inability to remember the event Dyskinesia: abnormal involuntary muscle rigidity Dystonia: involuntary repetitive muscle movements resulting in abnormal movements and postures (continuous muscle spasm)

ELDERLY

Name

Cause

Signs/Symptoms

Retinal Detachment

Risk factors are extreme nearsightedness, hx of cataract surgery, and family or personal hx or retinal detachment

New onset or sudden ↑ in number of floaters or specks on the visual field, flashes of light and sensation that a curtain is covering part of the visual field.

Temporal Arteritis (Giant Cell Arteritis)

Temporal headache (one sided) with tenderness or induration over temporal artery; may be accompanied by sudden visual loss in one eye (amaurosis fugax). Scalp tenderness on affected side.

Acute AngleClosure Glaucoma

Older adult with acute onset severe eye pain, severe headache, N/V. Eye is reddened with profuse tearing. Complains of blurred vision and halos around lights.

CVA

Sudden onset of neurological dysfunction that worsens with hours. Blurred vision, slurred speech, one-sided upper and/or lower extremity weakness, hemianopsia, confusion. Signs and symptoms are dependent upon location of infarct.

Actinic Keratosis

Fracture of Hips

Sun-exposure – precursor of Squamous cell carcinoma

Small rough pink to reddish lesions that do not heal. Located in sun exposed areas such as cheeks, nose, back of neck, arms, chest. More common in light skinned individuals.

Hx of osteoporosis or osteopenia

Acute onset limping, guarding and/or inability or difficulty with weight bearing on the affected side.

New onset of hip pain; may be referred to the knee or groin. Unequal leg length. Affected leg is abducted (turned away from body)

Colorectal cancer

Severe bacterial infections

Multiple Myeloma

Pneumonia, sepsis, Pyelonephritis, bacterial endocarditis

Diagnostics

Treatments

Concerns

Treated with laser surgery or cryopexy (freezing)

Can lead to blindness if it is not treated.

Screening test is ESR

Can lead to blindness

Call 911 Tonometry is done to measure intraocular pressure

TIA is temporary episode that last 24 hours.

Cryotherapy. Large numbers with wider distribution are treated with 5-fluorouracil cream.

Major cause of morbidity and mortality in the elderly. 20% of elderly with hip fractures die from complications (pneumonia)

Unexplained iron deficiency, anemia, blood on rectum, hematochezia, melena, abdominal pain or change in bowel habits. Tenesmus (feeling of incomplete defecation), rectal pain, diminished caliber stools (ribbon like or pencil like stools – indicated issue - descending colon)

Refer to GI

Atypical presentation is common. May be afebrile.

WBC can be normal. Sudden decline in mental status, new onset of urine/bowl incontinence, falling, inability to perform ADL, loss of appetite.

Most common is UTI

Cancer of bone marrow that affects plasma cells of immune system. Found in mostly older adults.

African descent has 2-3x higher incidence than whites. Presents with bone pain and generalized weakness

CBC, FOBT, chemistry panel, UA.

Refer to hematologist

ELDERLY

Name

Cause

Signs/Symptoms

Diagnostics

Pancreatic Cancer

Weight loss, anorexia, jaundice, weakness (asthenia) and abdominal pain.

AST, ALT, alkaline phosphatase, bilirubin, lipase and amylase

Alzheimer’s

Rare before 60. ↓ in acetylcholine production.

Aphasia – difficulty verbalizing Apraxia – difficulty with gross motor movements such as walking Agnosia – inability to recognize familiar people or objects

Parkinson’s

Progressive neurodegenerative disease ↓dopamine receptors. Tremors (worse at rest), muscular rigidity, and bradykinesia. Pill rolling, cogwheel rigidity, walks with shuffling gait, poor balance and falls often. Anxiety, depression, excessive daytime sleepiness. Difficulty with executive function (making plans, decisions, task).

Seborrheic dermatitis common

Essential Tremor

Usually seen in arms or hands and progress to head. Tremors may get worse with anxiety.

Most common cause of dementia followed by vascular dementia Difficulty with executive functioning, judgement.

Check vitamin B12

Treatments

Concerns

Refer to GI surgeon for Whipple procedure.

Most lethal cancer. Most people already have metastasis by the time of diagnosis. 5 yr. survival rate is 8.2%

MMSE 10-26 (mild to moderate) – Donepezil, rivastigmine, galantamine, Namenda MMSE < 17: add Namenda MMSE < 10: continue Namenda or discontinue. Add vitamin E 2,000 IU First line: Carbidopa-levodopa (Sinemet) – start low Sinemet 25/100 (1/2 tab) PO BID to TID with meals. Titrate up slowly.

Do not discontinue abruptly Others: Dopamine agonist Bromocriptine (Parlodel) or pramipexole (Mirapex) – can cause impulsive behavior; MAO-B inhibitor: Selegiline (Eldepryl) increased risk of serotonin syndrome or rasagiline (Azilect) Propranolol 60-320 mg per day – contraindicated: Asthma, COPD, 2nd-3rd degree heart block, bradycardia Primidone (mysoline) at bedtime Refer to neurologist

BEERS LIST CRITERIA Drug Class Antihistamines Benzodiazepines Antipsychotics Atypical antipsychotics Tricyclic antidepressants Cardiac drugs Alpha-blockers Sulfonylureas NSAIDs Mineral oil, PPI Ambien, Lunesta Antispasmodics Other

Drugs to Avoid Benadryl, chlorpheniramine Short-intermediate: Xanax, Ativan, Halcion (long acting – Valium, Klonopin) Thioridazine (mellaril), mesoridazine (serentil) Seroquel, Zyprexa – Monitor BMI, Lipids, TSH, glucose Elavil, Tofranil, doxepin Orthostatic hypotension Terazosin, clonidine, higher risk hypotension Glyburide, chlorpropamide High risk of GI bleed Aspiration pneumonia, ↑ risk C Diff in hospital, ↓ absorption Ca, Mg Adverse effects with minimal improvement in sleep Bentyl, scopolamine, belladonna Reglan (except for gastroparesis); Insulin sliding scale

Gingko biloba- may help with memory (do not mix with ASA or warfarin)

Treatment for tardive dyskinesia (EPS): Benztropine (Cogentin) Amantadine (Symmetrel)

Postural tremor (not a resting tremor)

PEDIATRICS

NEONATE ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢

Best vision 8-12” (breast to mom’s eyes) Bluish scleral tint regardless of ethnicity Light sensitive eyes Defensive blink present at birth Visual preference for human face Hears high-pitched voices best Reacts to cry of other neonates Well-developed sense of smell Makes 6 wet diapers per day Breastfed make around 4 stools per day Newborns often lose up to 10% of birth weight in the first week of life, but are back up to birth weight by week 2

REFLEXES ➢

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DISCIPLINE ➢

Time Out – short term isolation to decrease undesirable behavior; sits in safe special place uninteresting and only used for time out; use timer o Can start at 18-24 months o Remains in time out for 1 min for every year of life

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RANDOM PEARLS

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Multi-system disease affecting skin, lymph etc. typically viral Birth weight doubles at 6 months and triples 12 months Screen for autism at 18 and 24 months Age appropriately resist exam

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16-18 months o 16-25% 19-21 months o 50% 2-2.5 years o 75% 3-4 years o 100%

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TOOTH ERUPTION ➢ ➢ ➢ ➢ ➢

Incisors first to erupt Upper central incisors 812 months Lower central incisors 610 months If no teeth by 12mon then consult dentist Molars are 1st permanent

DEVELOPMENTAL RED FLAGS ➢ ➢ ➢ ➢ ➢

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SPEECH MILESTONES ➢

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Moro reflex – throwing out arms and legs followed by pulling them back into body following sudden movement or loud noise (gone by 16 weeks) Palmar grasp – grasp object placed in palm (gone by 2-3 months) Babinski reflex – stroking of sole of foot elicits fanning of toes (gone by 6 months) Parachute reflex – arching of back and head raises when placed on stomach (last until 12 mos.)

Tonic neck reflex – when stimulating the back, the trunk and hips move toward side of stimulus (gone by 9 months) Stepping reflex – walking motion made with legs and feet when held upright and feet touching the ground (appears 3-4 months and reappears at 12-24 months) Rooting reflex – turning of head and sucking when cheek is stroked (gone by 6-12 months)

DEVELOPMENT

6 months – no big smiles or other warm, joyful expressions 9 months – no back-and-forth sharing of sounds, smiles or other facial expressions 12 months – lack of response to name, no babbling or baby talk, no pointing, showing, reaching or waving 16 months – no spoken words 24 months – no meaningful two-word phrases that do not involve imitating or repeating

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2 months o From tummy can lift self-up on 2 arms o Responds 2 sounds o Smiles when smiled 2 4 months o Reaches 4 a toy or other object o Smiles 4 fun o Rolls from tummy to back 6 months o Looks like the number 6 when sitting up o Rolls from back to tummy and back 8 months o Once able to sit up child can transfer objects from hand to hand 12 months o Walking 18 months o Can name single word objects o Acts like an 18-yr. old by coping work that adults do o Says no 2 years o Speaks in 2-word sentences o Follows 2 step commands o Builds a 2-block tower o Can walk up 2nd floor with help 3 years o Rides a tricycle o Speaks in 3-word sentences o Can draw a circle o Builds a 3-block tower o Foreskin is not easily retracted until about 3 yrs. of age 4 years o Copies a cross o Draws a person with 3 body parts

PEDIATRICS

OFFICE VISIT ➢

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2-3 days after birth o Assess for jaundice o Breastfeeding o Weight change o Status of newborn screening o Maternal well-being o Infant care teaching 1 week o Gaining weight o Elimination patterns o Sleep/wake cycle o Parent-infant interaction o Review status of newborn screen o Milia, port wine stain, nevus simplex (stork bite), Mongolian spot o Fontanels – posterior close 3 months; anterior close at 9-18 months o Eyes – hypertelorism (eyes far apart), often cross until 2 months o Low set ears may indicate kidney issue o Hearing problem – interventions by 6 months o Clavicles – palpate both – if broken, move infant as single unit o Palpate femoral pulses – coarctation of aorta o Umbilical cord – silver nitrate stick o Genitalia o Fat pads on infant feet can resemble Pes Planus (flat feet) o Spine - Look for neural tube defect. If tuft of hair - sono Hyperbilirubinemia - > 5 o Immature liver cannot get rid of bilirubin fast enough; breakdown of RBC; Bili deposited under skin. Concerns for kernicterus

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NUTRITION

DIABETIC SCREENING IN KIDS

Breastfeeding up to 6 months Delay complementary foods until 4-6 months o Single ingredient – iron rich rice cereal o Cow’s milk at 12 months Vitamin D for breastfed babies

➢ Overweight or obese plus 2 additional risk factors o Family hx of T2DM in 1st/2nd degree relative o Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) o Acanthosis nigricans, HTN, dyslipidemia, PCOS, small for gestational age o Maternal hx of DM or gestational DM ➢ Initiate testing at age 10 or onset of puberty (Tanner 2) – every 3 years. ➢ Treat dyslipidemia in kids with weight loss

ASSESSMENT ➢

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Eyes – red reflex, visual acuity o Amblyopia – loss of vision; most common vision problem in kids o Corneal light reflex and cover/uncover o Strabismus – refer at 3 months ophthal. o 20/20 at age 6 Ears – assess for speech delay Heart – murmurs common and rate decreases as heart grows o BP at age 3 GI – umbilical hernia easily reducible Musculoskeletal – assess dysplasia of hip o Barlow – femoral head toward butt o Ortolani o Galeazzi – hip dysplasia o Club foot – talipes equinovarus - ortho o Metatarsus adductus o Can you move feet to midline? o If yes – instruct parents to move 10x with diaper changes o If not- ortho

Club Foot

Metarsus Adductus

PEDIATRICS

ASSESSMENT ➢

Musculoskeletal o Scoliosis – risk greatest during puberty o 10-degree curvature of spine o Adams forward bend o Scoliosis series (full length PA/Lateral) o More curvature at a young age indicates worse problem

TANNER STAGING ADOLESCENCE ➢ ➢

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VOMITING ➢

For all kids with vomiting – look at weight and growth chart o Rehydrate with pedialyte

Identity vs Role Confusion Early (10-14) o Egocentric! Concrete thinking with early moral struggles, progression of sexual identity, body image o Emotional separation from parents, identify as a person, peer identification, early exploration of harmful health behaviors such as substance abuse; engage in risky behavior – wear seatbelts Middle (15-17) o Peer groups more important than you.

Increased abstract thinking, “bullet proof”, growing verbal abilities, identification of law with morality, start fervent ideology (religious, political) – black and white thinkers o Increasing emotional separation from parents, strong peer identification, increased health risk – smoking, alcohol, early educational and vocational plans Late (18-21) o Complex abstract thinker increased impulse control, further development of personal identity, development or rejection of religious and political ideology o Development of social autonomy, increasingly complex intimate relationships, development of vocational capability and financial independence

➢ Tanner 1: looks like a baby ➢ Tanner 2: thelarche (breast budding), testes and scrotum start to enlarge; pubarche (onset of sparse pubic hair) o General rule breast budding to first menses (2 years) o Official start of puberty ➢ Tanner 3: onset of growth spurt (tallest finger) o penis lengthens o breast enlargement – one mound o gynecomastia can be seen here o pseudogynecomastia - overweight ➢ Tanner 4: female menstruating o Most girls hit adult height 1 yr. after starting menses o Areola elevated from breast (secondary mound) o Penis widens, and testes are larger with darker scrotal skin & more rugae ➢ Tanner 5: full adult ➢ Tanner 2-4 Boys: Balls→Long→Wide ➢ Tanner 2-4 Girls: Boobs – bud → 1 → 2 ➢ Normal onset puberty Girl 8-13 ➢ Early onset puberty before age 7-8 (idiopathic – refer pedi endo) - > 13 nutrition with low weight (eating disorders, gymnast, genetic) ➢ Normal onset puberty Male 9-14 o Refer pedi endo for early onset

PEDIATRICS

LIVE IMMUNIZATIONS

IMMUNIZATIONS ➢ ➢

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Spacing of Vaccines o 4 days before due is ok – 5 days prior is INVALID Hepatitis A o Universally recommended age 1 o 2 dose series at least 6 months apart Hepatitis B o 3 dose series: 0, 1-2 months, 6 months DTaP (< 7 years) – minimum age 6 weeks o #1 at 2 months o #2 at 4 months o #3 at 6 months o #4 at 15-18 months o #5 at 4-6 years Tdap > 7 years o 11-12 o Td booster every 10 years o Every pregnancy 3rd trimester Hib o 2, 4, 6 and 12-15 months o For unvaccinated 15+ months administer only one dose Pneumococcal vaccine (PCV13) o 2, 4, 6 and 12-15 months o Vulnerable populations also get PCV23 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 Flu vaccine o Every year Meningococcal Conjugate vaccine (MCV4) o All children age 11-12 o BOOSTER age 16 HPV-9 o Age 9-14 – 2 dose series at 0 and 6-12 months o Avoid in pregnancy, ok if breastfeeding

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Must replicate to reproduce immunity – run fever and/or rash Avoid before age 1 MMR o 12-15 months and age 4-6 Varicella o 12-18 months and age 4-6 o If given at age 13 or later, 2 doses are required at least 1 month apart o Contraindicated if allergic to neomycin or gelatin Must wait 28 days between live vaccines

ADVERSE REACTIONS TO IMMUNIZATIONS ➢ ➢

Local (redness), systemic (fever) or allergic Syncope with HPV, MCV4 and Tdap

RULES ABOUT NODES ➢ ➢

10mm is enlarged Exceptions o Epitrochlear > 5mm o Inguinal > 15mm o Cervical > 20mm

PEDIATRICS

DEHYDRATION Pulse BP

Mild Normal Normal

Respiration

Normal

Mucosa Anterior fontanel Eyes Skin turgor Skin Urine output Systemic signs

Sticky Normal Normal Normal Normal Normal Thirsty

Moderate Rapid Normal to low Deep, ↑ rate Dry Sunken Sunken Reduced Cool Reduced Irritable

Severe Rapid and weak low Deep, ↑ rate Parched Very sunken Very sunken Tenting Cool, mottled None Lethargy

Can they hold fluids down?

UNDESCENDED TESTES ➢ ↑ risk of testicular cancer ➢ Cryptorchidism – undescended ➢ Retractile testes – moves between scrotum and inguinal ring ➢ Refer if not descended by 6 months

PINWORMS ➢ Enterobiasis ➢ 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 ➢ Usually happens 4-8 weeks after exposure ➢ Treat with Albendazole ➢

CONGENITAL HEART DISEASE ➢ Innocent Murmur Clues: o Grade < 2 o Softer when sitting than when supine o Not holosystolic o Minimal radiation o Musical or vibratory quality ➢ Pathologic Murmur Clues: o Grade > 3 o Holosystolic o Max intensity at LUSB o Harsh or blowing o Systolic clicks o Diastolic murmur o ↑ intensity in upright position o Gallop rhythm o Friction rub

PEDIATRICS

Name

Cause

Signs/Symptoms

Diagnostics

Jaundice

Physiologic jaundice occurs in absence of liver disease; jaundice arise from problems with liver

Galactorrhea

Maternal hormonal influences

Breast milk production in the absence of lactation, usual onset day 3-4 of life. Breast engorgement will resolve without intervention within first 2 months of life.

Some cultures think this is a curse so be sure to ask how if this has any effect on the family.

Chlamydial (inclusion) conjunctivitis

Exposure to Chlamydia

Signs and symptoms 5-14 days post exposure.

Bilateral lid swelling, chemosis, mucoid drainage

Oral erythromycin x 2 weeks due to pneumonia risk Prevention: 3rd trimester STI screening

Usually seen in face and progress caudally to trunk and extremities

Fever, sore throat, malaise, nasal discharge, diffuse maculopapular rash lasting about 3 days.

Posterior cervical and postauricular lymphadenopathy beginning 5-10 days prior to onset and present during rash; arthralgia in about 25% Fever, nasal discharge, cough, coryza, generalized lymphadenopathy, conjunctivitis (clear copious discharge), photophobia – Koplik spots, pharyngitis, maculopapular rash 3-4 days and may coalesce to generalized erythema, starts on head and neck

Treatments

Concerns

Prevention: encourage breastfeeding every 2-3 hours daily

Physiologic jaundice occurs after 24 hours of life Jaundice within first 24 hours of life typically involves liver problems

Lab confirmation of serum rubella IgM

Notifiable condition – droplet transmission – public health dictates when child goes back to school Mask patient until she gets home Prevention with MMR vaccine

Lab confirmation of serum rubeola IgM

Notifiable condition Prevention with MMR vaccine

Rubella (German measles, 3-day measles)

Rubella virus

Rubeola (measles)

Rubeola virus

Roseola Infantum

HPV 6

High fever for 2-4 days followed by maculopapular rash on body (body pink – roses are pink)– face not affected

Self-limiting

Usually around 7-13 months

Erythema Infectiosum “Fifth disease”

Parvovirus B19 – spread through resp. secretions

“slapped cheek” rash; lacy, maculopapular Significant risk of miscarriage in pregnant mother if exposed particularly in 1st trimester

Self-limiting

When can child go back to daycare – fever free for 24 hours

Hand, foot and mouth disease

Coxsackie A Virus

Fever, malaise, sore mouth, anorexia; 1-2 days later, lesions; can also cause conjunctivitis and pharyngitis; last 2-7 days

Prevent dehydration – resolves in 2-3 days

Do not confuse with herpangina – sores in mouth

Vasculitis of coronary arteries

Fever for 5 days plus bilateral conjunctival injection, polymorphous, macular rash, inflammatory changes of lips and oral cavity (strawberry tongue), cervical lymphadenopathy, edema or desquamation of hands and feet

Refer for IV immune globulin High dose aspirin Aspirin daily for 2 months

More common in male than females

Kawasaki Disease

CBC, ESR or CRP, ALT/AST, UA, throat culture, Echo ↑platelets (poor man sed rate)

Teratogenic virus

PEDIATRICS

Name

Cause

Signs/Symptoms

Mononucleosis

Epstein Barr virus

Fever, shaggy purple white exudative pharyngitis, malaise, marked diffuse lymphadenopathy, hepatic and splenic tenderness with occasional enlargement; maculopapular rash in 20% (rare petechial rash)

Monospot (heterophil antibody test)

Iron deficiency anemia

Depletion of birth iron stores, initiation of lower-iron diet in later infancy, early toddler stage

Most common in ages 12-30 months

Microcytic, hypochromic, elevated RDW

Croup (laryngotracheobronchitis)

Viral

Barky cough with or without stridor

Foreign body

Mechanical obstruction

Inspiratory stridor

Peritonsillar abscess

Bacterial

Hot potato voice, difficulty swallowing, trismus and contralateral uvula deviation; possible stridor

Airway maintenance, ED, ENT consult, antimicrobial therapy, inpatient admission, surgical intervention

Acute epiglottitis

H. influenzae

Adult with dysphagia and drooling; stridor, hoarseness, sore throat, fever, “thumb sign”

Airway maintenance, ED, ENT consult,

Bronchiolitis

Virus - RSV

Fever, cough, ↑ RR, Happy wheezer; 3 months to 3 years; wheeze may persist up to 3 weeks

Supportive therapy – hydration, oxygen (no bronchodilators, no steroids) Prevent with synagis (only a few qualify)

Wilms tumor

nephroblastoma

Asymptomatic abdominal mass that extends from flank to midline. Light palpation to avoid rupture

Involuntary stooling

Underlying problem is usually constipation.

Intestines are full of stool – child loses sensation to defecate

Encopresis

Diagnostics

Treatments

Concerns

If pt. has mono do not give Amoxicillin – will have morbilliform rash

Often associates with teenagers and adults because they are more symptomatic than young children Lead toxicity masquerades as IDA – abdominal pain, fatigue, irritability

Supportive, systemic corticosteroid therapy – Decadron (one dose due to ½ life of 72 hours)

CXR 2 view

Removal, referral to ED

FB in nose may present with unilateral purulent drainage

Typically affects < 1 yr.

↑ risk in black female, peak age 2-3

ultrasound

Laxatives for initial cleansing daily until normal stools (MiraLAX). Behavior changes (sit for 5 minutes 2-3x daily after meals to establish normal BM).

Dietary changes: fiber, fluids

More common in males.

Feel safe going to bathroom at school?

Females – investigate sexual abuse

PEDIATRICS

Name

Cause

Signs/Symptoms

Hyperactivity, Impulsivity and inattention Combined: meets criteria of BOTH inattention and hyperactivity/impulsivity Predominantly inattentive Predominately hyperactivity/impulsivity

ADHD

Diagnostics

Treatments

Concerns

Symptoms must be present prior to age 12 years; symptoms last > 6 months; Be evident in 2 different settings (school and home)

Document > 6 symptoms of inattention Use rating scale (Child behavior checklist, Conners’ rating scales, Vanderbilt ADHD rating scales, others) If co-morbidities are present – refer Commonly treated with Schedule 2 meds

Do not confuse with someone who has sensitivity to decongestants; hyperthyroidism; pinworms

Same as adults except: Leukotriene receptor – Singular (1 in 3) Nebulizer or spacer

Most common chronic disorder in children

Asthma

Disease of inflammation

Same as adults

Pneumonia

Commonly viral If bacteria – Strep pneumo

Most sensitive finding is ↑ respiratory rate

Chest x-ray CBC

Autosomal recessive

Excessive loss of sodium through sweat (cannot transport sodium and chloride – making mucous thick and tenacious); Recurrent sinus and pulmonary infections, mucous can block ducts of pancreas and cause weight loss and greasy stools

Sweat test

Cystic Fibrosis

High dose amoxicillin 90 mg/kg/day

Multisystem disease – pulmonary, GI, sweat glands European descent

↓ WBC ↓ H/H ↓ Platelets Peripheral smear: malignant cells Bone marrow: infiltration with blast cells

Leukemia

Most common form of cancer

Fever in the evening, bruising, bleeding, frequent nosebleeds, bone pain, recurrent infections, lymphadenopathy, fatigue, poor appetite, hepatosplenomegaly. Failure of bone marrow

Pyloric Stenosis

Narrowing of pyloric sphincter due to hypertrophy of pyloric muscle

Projectile vomiting, first-born males, nonbilious vomiting. Olive like mass palpated in RUQ

ultrasound

Differential diagnosis: GERD, milk protein intolerance, intestinal obstruction Surgery

LES immature to 9-12 months

Frequent regurgitation in absence of anything pathological; occurs 30+ times in healthy infant – irritability during a reflux episode indicated GERD rather than GER

Red flags: choking with eating, coughing with eating, forceful vomiting, GI bleed, poor weight gain, refusal to feed, constipation or diarrhea, abdominal tenderness, fever

Usually preventative measures – continue to breast feed, place supine to sleep, small frequent, thickened feedings, consider non-cow’s milk protein formula for 1-2 weeks, soy-based formula, 1-2-week trial of hypoallergenic formula

Intestinal obstruction

Sudden onset intermittent, crampy, progressive abdominal pain – acts normal between painful episode. Cries and pulls knees up to chest. Current jelly stools, sausage shaped mass

KUB, ultrasound

Barium enema Possible surgical correction

Gastroesophageal reflux (GER)

Intussusception

Most common age 2-8 ALL – 77% AML – 11%

Typically occurs at 4-6 weeks;

Typically, less than age 2

PEDIATRICS

Name

Cause

Signs/Symptoms

Diagnostics

Treatments

Concerns

Legg-Calve Perthes Disease

Avascular necrosis of proximal femoral head

Limp; pain to hip and/or knee

Trendelenburg’s (stand on affected side causes pelvic tilt) Hip x-ray (AP and frog leg)

Refer to ortho

Ages 3-12 Affects males > females

Slipped Capital Femoral Epiphysis (SCFE)

Femoral head slips out of hip joint

Several weeks or months of hip/knee pain with intermittent limp

Trendelenburg’s (stand on affected side causes pelvic tilt) Hip x-ray (AP and frog leg)

Refer to ortho – surgical repair with internal fixator

Common in adolescents

Fragile X syndrome

Males: Large forehead, ears, prominent jaw, tendency to avoid eye contact, large testicles (macroorchidism) large body habitus, hx of learning and behavioral differences Females: less common with fewer prominent findings

Blood testing for carrier state

Klinefelter syndrome XXY male

Low testicular volume, hip and breast enlargement, infertility. Mostly developmental issues, most commonly language impairment

Blood testing for carrier state

Turner syndrome XO

Short stature (less than 5 ft.) wide, webbed neck, broad, shield-shaped chest, absent menses, infertility; born without ovaries, high narrow arched palate, retrognathia, low-set ears, edema of hands and feet – mosaic Turner’s have milder features

Blood testing available; High rate of pregnancy loss

Osgood Schlatter Disease Common in growth spurt Tx: Rest, activity as Tolerated; RICE

Most common known cause of autism