AANP and ANCC Nurse Practitioner Study Guide

Integumentary:
Most common cancer in the USA:
 Skin cancer

Most common type of skin cancer:

 Basal Cell Skin Cancer

Basal Cell Carcinoma (BCC):

Symptoms:
 Pearly, waxy, skin lesions, atrophic, ulcerated center that does not heal
 Raised edges and telangiectasia (tiny blood vessels)
 May ulcerate (center of lesion)
 May easily bleed with trauma
 Common locations: cheeks, nose, face, neck, arms, and back
Dx:
 Gold Standard: Biopsy
o If biopsy is not an option refer to Dermatology

Actinic Keratosis:
Symptoms:
 Precursor to Squamous Cell Carcinoma
 “Numerous dry, round, and pink to red lesions” with a rough and scaly texture
 Does not heal. Slow growing in sun exposed areas
Dx:
 Gold Standard: Biopsy
o If biopsy is not an option refer to Dermatology
Treatment:
 Small number do cryotherapy
 Large number 5-FU cream (5-Flouracil aka Efudex)
o Which causes the skin to ooze, crust, scab, and be red
■ Should wear sunscreen with medication due to side effects
mentioned

Squamous Cell Cancer:

Symptoms:
 Chronic red scaly rough textured lesion with irregular borders
 Sometimes crusting or bleeding
 Common locations: Rims of the ears, lips, nose, face and top of hands
 Precursor lesion: Actinic Keratosis
Dx:
 Gold Standard: Biopsy
o If biopsy is not an option refer to Dermatology
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Risk factors for skin cancer (both melanoma and non-melanoma):

 Blistering sunburn as a child, history of sunburns, light skin, chronic exposure to
UV light (sunlight, tanning beds), moles, family history for skin cancer
 Time of day when the sun is most damaging is between 10 AM-3 PM

Melanoma:
Symptoms:
 A-asymmetry (shape, uneven texture)
 B-border (irregular, notched, blurred)
 C-color (variegated colors from black, blue, dark to light brown)
 D-diameter (size >6mm size of pencil eraser or larger)
 E-evolving (changes in color, size, or shape)
 May be itchy
 ABDCE’s of skin cancer
Dx:
 Biopsy is first line diagnosis
o Refer to Dermatology if biopsy is not an option
 *Be able to identify a picture

Acral Lentiginous Melanoma:

 Most common type of melanoma in dark-skinned individuals (Blacks and Asians)
Symptoms:
 Look for longitudinal brown to black bands under the nailbed. A changing spot or
mole in the palms, or the soles of the feet

Seborrheic Keratosis:
Symptoms:
 Soft round wart-like growth that is light tan to black and looks pasted on
 Asymptomatic and benign

Bacterial Meningitis:
Bacteria:
 Streptococcus pneumoniae (most common)
 Haemophilus influenzae
 Neisseria meningitidis
 Escherichia coli
 Others
Symptoms:
 Classic Triad:
o High fever
o Nuchal rigidity
o Rapid change in mental status with headache
■ Test Tip: Triad is neck up
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 Erythematous spot-like rash (petechiae), ecchymosis to purple-colored lesions

(purpura) which are non-blanchable
 Reportable disease
Treatment:
 Close contacts should be treated with Rifampin 600 mg every 12 hours x 2 days
o Rifampin changes urine color to reddish orange and can stain contacts
o Avoid in pregnant women

Brudzinski Sign (nuchal rigidity):

 Tests for meningeal irritation
o Patient supine. Raise Back of head and flex chin towards chest
■ Positive result if patient automatically bends both hips
■ Brudzinski and Back of head start with a “B” as well as Bends

Raise Back of head of pt. and flex chin

Positive if pt. automatically Bends both hips

Kernig’s Sign:
 Tests for meningeal irritation
o Patient supine. Flex patients hips and knees in a right angle, then slowly
straighten/extend the leg up.
■ Positive result is when the patient complains of pain during
extension of leg.
Start
with pt.’s. knee at 90O then

Positive if pt. has any pain

MCV4 (Menactra, Menveo) Quadrivalent Meningococcal Vaccine:

 Age 11-19:
o Give one dose of Menactra or Menveo.
o If primary dose given age 12 or younger give a booster at age 16 to 18
 Age 19 to 21:
o Give one dose of Menactra or Menveo if never had either
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Rocky Mountain Spotted Fever (RMSF):

Symptoms:
 Fever
 Chills
 Nausea and Vomiting
 Myalgia
 Arthralgia
 2-5 days later develop petechial rash on forearms, ankles, and wrists that spreads
towards trunk and becomes generalized. Sometimes rash develops on the palms
and soles
o Rash spreads inwards
o Mnemonic:
■ RMSF
 R-Rash
 M-Muscle aches (myalgia)
 S-Stomach aches (nausea and vomiting)
 F-Fever (>102O F)
Located:
 Think “Rocky”- North Carolina, Oklahoma, Arkansas, Tennessee, Missouri
 Spring to Fall (April to September)
Dx:
 PCR assay by indirect immunofluorescence antibody (IFA) assay for
immunoglobulin G (IgG) for Rickettsia Rickettsii
Treatment:
 Doxycycline is always first line for all ages
o 100 mg every 12 hours x 7-10 days
 Can be fatal if not treated within the first 5 days

Erythema Migrans (early Lyme disease):

Symptoms:
 Usually appears in 7-14 days after being bitten by a deer tick; range 3-30 days
 Target bull’s-eye
 Rash is hot to touch with rough texture. Expanding red rash with central clearing
 Common locations are belt line, axillary area, behind the knees, and groin area
 Positive for flu like symptoms. Lesions and rash resolve within a few weeks with
or without treatment
Dx:
 First step is enzyme immunoassay (EIA) also knows as ELISA if negative no
further testing needed. If positive confirm with Western Blot test (aka indirect
immunofluorescence assay (IFA) for Borrelia Burgdorferi
o Exam Tip: E before I
 Will have increased ESR
Treatment:
 Doxycycline is always first line for all ages
o 100 mg BID x 10-21 days
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Remove ticks by grasping with tweezers or forceps close to the skin and pulling gently with
steady pressure. After removing the tick, clean area with rubbing alcohol, iodine scrub, or soap
and water. Dispose of the tick by flushing it into the toilet

Types of Tick Repellant:

 For skin use: DEET
 For clothing use: Permethrin

Brown Recluse Spider Bite:

Symptoms:
 Fever, chills
 Nausea and Vomiting
 Located in the arms, upper legs, or the trunk
 Bitten area becomes swollen, red, and tender, or can be painless
 Blisters appear within 24-48 hours
 Necrotic in center, which kills the tissue
Treatment:
 Ice packs to wound as the cold inactivates the toxin
 Treat like cellulitis of the skin
 Antibiotic ointment at first and watch

Skin Lesions:
 Primary Skin Lesions

Macule
Vesicle
Papule
MVP
Size: <1 CM

Macule- flat and nonpalpable (freckles)

Vesicle- elevated, raised lesion filled with serous fluid (herpetic lesions)
Papule- palpable solid lesion (acne, moles)

Nodule
Plaque
Bullae (Blister)
Pustule
Wheal
Size: ≥1 CM
Nodule-raised solid lesion (BCC)
Plaque- solid raised lesion with flat top (psoriasis)
Bulla/Bullae- elevated superficial blister filled with serous fluid (2nd degree burn, impetigo)
Pustule-circumscribed elevated lesion containing pus (acne pustules)
Wheal-a raised area of skin (mosquito bite, hive)
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 Secondary Skin Lesions

Lichenification- thickening of the epidermis with exaggeration of normal skin due to chronic skin
itching (eczema)
Scale- flaking skin (psoriasis)
Crust- dried exudate (impetigo)
Ulceration- eroding of epidermis and dermis (if deep can involve subcutaneous tissue)
Scar- permanent fibrotic change following damage to dermis (surgical scars)
Keloids/Hypertrophic scars- overgrowth of scar tissue (more common in Black and Asian descent)

Rule of 9’s:
Always assess the ABC’s

Adult Child
One arm 9% 9%
Chest 18% 18%
One leg 18% 13.5%
Head 9% 18%

Stages of Burns:
 First degree (superficial):
o Red to bright red skin and tenderness/pain
 Second degree (partial thickness):
o Painful red skin, bullae (blisters), reddened/weepy skin
 Third degree (full thickness):
o Pain sensation absent. Pale/white color, charred skin, leather-like texture

Criteria for Burn Center Referral:

 Face, hands, feet, genitals, major joints
 Electrical burns, lightning burns
 Partial thickness burns >10% of total body surface area
 Third degree burns in any age group

 If pt. has a Sulfa allergy and can’t use Silvadene what is the alternative?
 Bacitracin, Polysporin/Triple antibiotic cream or ointment

Cellulitis:
Bacteria (Gram Positive):
 Streptococcus (beta hemolytic strep), Staph aureus (MRSA)
Symptoms:
 Diffused pink to red colored skin, warm to touch, and may become abscessed
 If red streaks radiating from infection it has spread to lymph nodes (lymphangitis)
 Usually within the deep dermis and is poorly demarcated (poor boundaries). Most
common location is the lower legs
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 If pt. has DM and develops cellulitis watch for osteomyelitis

Treatment:
 First line:
o Abscess/cellulitis is I&D (if <5 cm no PO antibiotic needed)
 Check for tetanus vaccine status
 Nonpurulent:
o Cephalexin (Keflex) 500 mg or Dicloxacillin q 6 hours for 5-10 days
 Purulent (MRSA):
o Wound culture
o Follow up in 48 hours
o Bactrim BS BID x 10 days
o If you suspect osteomyelitis order an MRI
 If allergic to Penicillin:
o Azithromycin (Z-Pack x 5 days)

Erysipelas:
Bacteria:
 Group A Streptococcus
Symptoms:
 Bright red plaque or induration with sharp or elevated margins on the face or
lower legs
 If fever and chills present pt. is septic (hospitalization is recommended)
Located:
 Involves upper dermis and superficial lymphatics
 Found on the cheeks and shins
Treatment:
 If treating facial erysipelas assume MRSA is present. Use appropriate antibiotics
or refer to ER if septic
 Dicloxacillin QID, Cephalexin or Clindamycin x 10 days
 If allergic to Penicillin:
o Azithromycin (Z-Pack x 5 days)

MRSA:
Treatment:
 Bactrim
 Doxycycline
 Minocycline
 Clindamycin
o If patient is allergic to Sulfa do not use Bactrim

Human bites (dirtiest bite of all)/Animal bites (P. multocida):

Animal bites:
Symptoms:
 Cat bites have a higher risk of infection that dog bites
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 Redness, swelling, pain

 Systemic symptoms may develop within 12-24 hours
Treatment of both:
 Augmentin 875/125 mg BID x 10 days or IV antibiotics in ER
o Penicillin Allergy
■ Doxycycline BID or Bactrim DS BID PLUS Flagyl BID or
Clindamycin TID
 Also give Tetanus booster if needed
 Evaluate for rabies prophylaxis

Tetanus Vaccination:
Initial series (3 doses) DTaP (infants to age 6): 5 doses
Ages 7 and older: Td or Tdap
Need every 10 years for lifetime
Common reaction: pain at injection site in 24-48 hours
Contaminated wounds: give one dose if last dose was more than 5 years ago or is due

Impetigo:
Bacteria (Gram Positive):
 Beta Streptococcus or Streptococcus aureus
Background:
 Most common bacterial skin infection in young children ages 2-5
Symptoms:
 Itchy pink-red lesions, evolve into vesiculopustules that rupture easily, honey-
colored crusts (from dried serous exudate)
 Very pruritic and contagious
Treatment:
 Order C&S of fluid
 Severe Case
o Keflex or Dicloxacillin QID x 10 days
 Penicillin Allergy
o Give Azithromycin 250 mg x 5 days or
o Clindamycin x 10 days
 If NO BULLAE
o Topical mupirocin ointment (Bactroban) 2% x 10 days
 *Be able to identify a picture

Acne Vulgaris (common acne):

Treatment:
 First line treatment is always topical retinoid such as tretinoin cream (Retin-A)
 Mild (topicals only) open comedones (blackheads)/closed comedones
(whiteheads) with or without papules
o Topical retinoid (Retin-A)
■ Acne will worsen during first 4-6 weeks
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■ If no improvement in 8-12 weeks increase dose or ADD benzoyl

peroxide and/or erythromycin
 Moderate (topicals plus antibiotics)- papules and pustules with comedones
o Topical retinoid (Retin-A)
o AND topical benzoyl peroxide
o AND oral antibiotic (Tetracycline or Minocycline) x 3-4 weeks
■ Exam usually asks about moderate
 Severe- painful indurated nodule, cysts, abscesses, pustules
o Accutane- check LFTs, must use 2 forms of contraceptives, monthly
pregnancy testing, only prescribe 1 month supply of medication
o Usually, will refer to Dermatology
Topical retinoid side effects:
 Irritation, dry skin, flaking, redness during first 4 weeks due to increase in
skin turnover
 After washing face wait 30 minutes before applying medication to help
minimize irritation
Avoid in Pregnancy:
 Category X: Topical tazarotene (Tazorac), Accutane
 Category C: Topical retinoids (tretinoin, adapalene)

Acne Rosacea:
Symptoms:
 Chronic small acne like papules/pustules, and telangiectasias around nose, mouth,
and chin symmetrically
Treatment:
 First line:
o (Avoid triggers of flushing (EtOH, excessive sun, spicy foods)
 Metro gel or Azelex gel QD-BID
 Low dose Tetracycline 250 mg QID or doxycycline 100 mg QD if gel not
effective or the patient has pustular/ocular rosacea

Psoriasis:
Symptoms:
 Inherited condition (atopy)
 Pruritic erythematous plaques
 Fine silvery-white scales with pitted fingernails
 Occurs on scalp, elbows, knees, sacrum, and intergluteal folds (extensor surfaces)
 Migratory arthritis
Koebner phenomenon:
 New psoriatic plaques form over skin trauma
Auspitz sign:
 Pinpoint bleeding when plaques are removed
Treatment:
 Topical steroids
o Seven classes of steroids
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o Avoid class I-III on children, and sensitive skin (face, groin, etc.)
o Class I- super potent
o Class VII least potent
 Tar preps (mild cases)
 Anti-TNF (severe cases) or immunologics
o Methotrexate, cyclosporine, etanercept, adalimumab

Atopic Dermatitis (Eczema):

Symptoms:
 Inherited condition (atopy)
 Extremely itchy
 On neck, and hands as well as other flexural folds

 Small vesicles (MVP- macule, vesicle, papule all are <1 CM all others ≥1
 An IgE condition

CM) that rupture leaving painful, bright-red, weepy lesions

 Will become lichenified from itching
Treatment:
 First Line:
o Topical steroids and emollients
 Avoid hot water/soaps
 Can take oral antihistamines to help with itching
 Avoid wool clothes

Contact Dermatitis:
Symptoms:
 Inflammation of skin that is caused by direct contact with an irritating external
substance
 Acute onset that can be located anywhere on the body
 Rash can be either linear or assume any shape
 It is very pruritic, and usually there is no lichenification. Lesions evolve into
vesicular bullae that easily rupture leaving bright-red moist areas that are painful
Treatment:
 First Line:
o Stop exposure to substance
 Topical steroids QD to BID x 1-2 weeks
 Consider referral to allergist for patch testing

Scabies:
Symptoms:
 Pruritic rash located in the interdigital webs of the hands, axillae, breasts, buttock
folds, waist, scrotum, and penis
 Severe generalized itching that is worse at bedtime
 Family member will have same symptoms
Treatment:
 Permethrin (Elimite) cream 5%
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o Apply cream to skin from neck to soles of feet. Leave on for at least 8-14
hours then rinse off. Repeat in 1 week
o Scabies never go to scalp!
o Treat everyone. Wash sheets and all other items in house in hot water

Pityriasis Rosea:
Symptoms:
 May be itchy
 Herald patch appears 2 weeks before full breakout
 Christmas tree pattern
 Rash on the hands or soles of the feet
Treatment:
 Resolves on its own in about 4-6 weeks
Additional:
 Test for secondary syphilis with RPR then VDRL as screening
 If positive then do FTA-ABS if this is positive patient has syphilis; treat
appropriately

Tinea Corporis (body-think of core):

Symptoms:
 Ring like itchy rash, slowly enlarges with central clearing
Treatment:
 Most respond to topical antifungals, if severe do oral Lamisil
o Med ends with azole on exam

Tinea Capitis (scalp-think of baseball cap):

Symptoms:
 Scaly round itchy patches on the scalp. Hair becomes fragile at the roots and
breaks (black dot sign)
Treatment:
 Oral meds only (Griseofulvin, terbinafine, fluconazole, or itraconazole)
o Obtain baseline LFT and repeat in 2 weeks
o Gold standard:
■ Griseofulvin QD-BID x 6-12 weeks
 Avoid hepatotoxic substances (alcohol, statins, acetaminophen)
 Avoid sharing combs, headgear, towels, pillows, and clothes with others

Tinea Cruris (groin):

Symptoms:
 Erythematous annular (ring-shaped) rash located in the groin area which can
sometimes extend to buttocks
 Usually associated with tinea pedis
Treatment:
 Azole topical cream (Lamisil, Lotrimin, Monistat-Derm) x 7-14 days
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Tinea Pedis (Hands/Feet- think pedicure):

Symptoms:
 Scaling of the soles
 Skin feels wet, strong odor, vesicles and bullae that rupture
 “Two feet and one hand” disease (dominant hand used for itching the
feet becomes infected)
Treatment:
 Azole topical cream (Lamisil, Lotrimin, Monistat-Derm) x 7-14 days

Onychomycosis aka tinea unguium (fingernail or toenail fungus):

Symptoms:
 Elderly with yellow-colored nails
 Thickened nails with debris
Treatment:
 Mild cases fingernails:
o Topical Penlac
 Toenails:
o Systemic antifungals either 6 weeks or pulse therapy (once per week for 3-
4 cycles)

Tinea Versicolor:
Cause:
 Yeast Pityrosporum orbiculare or P. ovale
Symptoms:
 Multiple hypopigmented round macules on chest, shoulders, and/or back that
appear after skin becomes tan from sun exposure
 Condition is asymptomatic
 KOH slide will show hyphae and spores (“spaghetti and meatballs”)
Treatment:
 Topical selenium sulfide and topical azole antifungals (Nizoral) or terbinafine
(Lamisil) cream BID x 2 weeks
 Hypopigmented spots may take several months to fill in

Herpetic Whitlow (caused by herpes simplex):

Symptoms:
 HSV 1 or HSV 2 infection
 Abrupt onset of small red papules/bumps which become vesicular
 Extremely painful, tingling, and burning sensation. Usually on index finger or
thumb
Treatment:
 Rest, elevation, and NSAIDs
o As this is a self-limiting infection
 If recurrent or severe infection can prescribe oral acyclovir
o DO NOT chose topical acyclovir as an option because it’s expensive and
does not work well
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Varicella Zoster Virus (VZV):

Symptoms:
 Contagious for 48 hours before and until all lesions are crusted over
 Low grade fever
 Generalized lymphadenopathy
 Intense itching
 Erythematous macules
 Papules develop over macules, then vesicles erupt
 “Initially on trunk, then scalp and face”
Labs:
 Gold Standard: PCR
Treatment:
 Supportive, antihistamines
 Oral Acyclovir if given within the first 24 hours; will work best

Subungual Hematoma:
Treatment:

o If blood is not drained and the hematoma involves ≥25%, there is a

 Treat subungual hematoma by trephination

high risk of ischemic damage to nail matrix

o Use either a large paperclip or 18-gauge needle and heat up the tip
o Position at 90O and apply steady pressure until you have blood draining
o Remove either the paperclip or needle and gently evacuate the blood

Systemic Lupus Erythematosus:

Symptoms:
 Maculopapular butterfly-shaped rash on the middle of the face (malar rash)
 May have nonpruritic thick scaly red rashes on sun-exposed areas
Treatment:
 Refer to rheumatology
 Avoid sunlight and other UV light exposure can worsen the disease
 Wear broad-spectrum sunblock that’s effective against UVA and UVB

Molluscum Contagiosum:
Cause:
 Poxvirus
Symptoms:
 White plug, dome shaped with central umbilication
 Highly contagious (spreads via skin-to-skin contact)
Treatment:
 Typically resolves on its own if immunocompetent (watchful waiting)
o Other options: cryotherapy, curettage, cantharidin
 If sexually active CDC considers this an STI if in genital region
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Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN):

Symptoms:
 Classic is target or bull’s-eye rash that occurs abruptly
 Hives and blisters
 Petechiae and purpura
 Necrosis with sloughing of tissue
 Extensive mucosal involvement
 Prodrome of fever with flu like symptoms
Triggers:
Mnemonic: SANA(p)
 Sulfonamides
 Anticonvulsants
 NSAIDs
 Allopurinol
 PCN
HIV patients are at a higher risk for SJS and TEN

Acanthosis Nigricans:
Symptoms:
 Velvety hyperpigmented patches most common on back of neck or skin folds
 Usually associated with diabetes, metabolic syndrome, obesity, and cancer of the
GI tract

Scarlet Fever (Scarlatina):

Symptoms:
 “Sandpaper textured-pink rash with sore throat” Strawberry tongue, rash starts on
head and neck, spreads to trunk. The skin THEN desquamates (peels/sheds)
 Associated with strep throat

Lichen Planus:
Symptoms:
 Small flat topped, red to purple bumps that may have white scales/flakes
 Wispy grey white streaks called Wickham’s striae
 Found on the inner wrists, forearms, and ankles. If on scalp causes hair loss
 Can be found in vulva and vagina with soreness, burning, and rawness
Treatment:
 Topical Steroids (even in vaginal area for Lichen Sclerosus)

Anthrax:
Symptoms:
 Animals/hides/hair/wool
 Lesions begin as papules that enlarges quickly within 24-48 hrs. Develop necrosis
and ulceration (sort of like a recluse spider bite)
 Not contagious
Treatment:
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 Doxycycline, Cipro, or Levaquin BID x 7-10 days

 If you suspect BIOTERRORISM treat for 60 days
 Prophylaxis antibiotics are Cipro and Doxy

Hidradenitis Suppurativa:
Symptoms:
 Recurrent episodes of painful large and tender red nodules, abscesses, and
pustules in the axilla (most common), groin, perianal, and inframammary
 Due to occlusion of the hair follicles and pilosebaceous glands (apocrine glands)
Treatment:
 Avoid skin trauma, wear loose light clothing, avoid excessive heat, and friction
 Smoking cessation, lose weight if obese
 Avoid deodorant
 Doxycycline QD to BID x several months
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Head/Ears/Eyes/Nose/Throat:
Blepharitis (inflammation of the eyelids):
Symptoms:
 Bilateral red and swollen edges of eyelids
 May have fine scales
 More common with seborrheic dermatitis
Treatment:
 Scrub eyelids in warm water and baby shampoo

Pterygium (Surfer’s eye):

Symptoms:
 Triangular-shaped white to yellow superficial growth
 On nasal side
 Caused by long term UV damage
Treatment:
 Surgical remove if it grows into the pupil
 Prevention: wear sunglasses

Pinguecula (think of Ping-Pong):

Symptoms:
 White to yellowish small round superficial lesion on each side of the cornea
 Caused by long term UV damage
Treatment:
 Prevention: wear sunglasses

Chalazion:
Symptoms:
 Small painless nodule
 Chronic inflammation of the meibomian gland (specialized sweat gland)
 Grows gradually
Treatment:
 Hot compress QID if large otherwise no treatment

Hordeolum (Stye):
Symptoms:
 Painful
 Swollen
 Red, warm, abscess, and it’s acute
 Think Hordeolum “Hurts”
Treatment:
 Hot compress until it drains QID
 Avoid wearing eye make-up
 Erythromycin or dicloxacillin QID if preseptal cellulitis develops
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o Refer to ophthalmology for I&D

Senile arcus:
Symptoms:
 White-gray ring on edge of cornea in elderly and is bilateral
o Normal finding in elderly
 Result of lipid deposit
Treatment:
 None
 Age less than 50 check lipid profile

Xanthelasma:
Symptoms:
 Soft yellow flat plaques on the upper and lower lids by the inner canthus or
palpebrum
 Cholesterol plaques
Dx:
 Order fasting lipid profile to rule out hypercholesteremia
Treatment:
 Trichloroacetic acid, surgery, laser

Allergic Conjunctivitis (Keratoconjunctivitis):

Symptoms:
 Typically, bilateral itchy eyes with “stringy discharge and increased tearing”
 Type I sensitivity (IgE)
 Rhinitis and allergic shiner
Treatment:
 PO (oral) antihistamines
 Eye drops olopatadine (Patanol), Visine (short term or episodic use only)
 Cool compresses and avoid allergens
*May be called keratoconjunctivitis on ANCC

Bacterial Conjunctivitis:
Symptoms:
 Acute onset of red eye
 Dried yellow-green crusting on eyelids on awakening
Treatment:
 Topical ophthalmic fluroquinolones (Ofloxacin) Q 2-4 hours x 2 days, then QID x
5 days

Viral Conjunctivitis (Pink Eye):

Symptoms:
 Acute onset of red eye
 Complaint of itchy eyes; one or both eyes
 Periauricular lymphadenopathy
 18

 Very contagious
Treatment:
 No treatment; frequent hand washing
 Keep away from school for 1 week

Herpes Keratitis:
Cause:
 Herpes Simples Virus or Shingles (Herpes Zoster)
Symptoms:
 Abrupt onset of eye PAIN, blurred vision, and tearing
 Vesicles and/or small rash on temple on affected side
 Follows the V1 branch (ophthalmic branch) of the trigeminal nerve (CN V)
Dx:
 Fluorescein dye
o Shows “fern-like” lesion
Treatment:
 Ophthalmologist or ER STAT

Corneal Abrasion:
Symptoms:
 Acute onset of severe eye PAIN
 Abrasion is round/irregular
 Foreign body sensation
Dx:
 Fluorescein dye. Will help rule out herpes keratitis
Treatment:
 Erythromycin ointment QID x 3-5 days
 DO NOT PATCH THE EYE
Alternative Meds:
 Sulfacetamide 10%
 Ciprofloxacin or ofloxacin

Acute Angle-Closure Glaucoma:

Symptoms:
 Acute onset of severe eye PAIN
 Decreased/Blurred Vision Normal ICP: 8-21
 Frontal Headache
 Nausea/Vomiting Acute Angle
 Cloudy cornea Glaucoma ICP >21
 Mid-dilated oval/ovoid shape pupil and in a fixed position
 Pupil does not respond to light
Treatment:
 ER STAT

TIP: Disc cupping is only seen with glaucoma which is caused by increased ICP
 19

Papilledema:
Symptoms:
 Optic disc swollen with blurred edges due to increased ICP (normal 8-21)
secondary to bleeding, brain tumor, pseudotumor cerebri, etc.
Treatment:
 ER

Primary Open Angle Glaucoma:

Symptoms:
 Affects CNII
 Gradual changes in peripheral vision which is LOST FIRST, then central vision
Treatment:
 Check IOP (use tonometer) if elevated should refer to ophthalmologist
 Medications: beta-blockers (timolol), topical prostaglandin eye drops (Xalatan)
o Avoid beta-blockers in patients who have asthma, emphysema, COPD, 2nd
or 3rd degree heart block, and heart failure

Cataracts:
Symptoms:
 Elderly with night vision issues
 Difficulty with glare (headlights when driving at night or sunlight)
 Halos around lights
Screening:
 Red Reflex Test
o If cataracts are present the red reflex will be missing from the affected
eye(s)
o Normal is a reddish-orange glow
o If no glow, dull, or white; the reflection is abnormal

Age-Related Macular Degeneration:

Symptoms:
 Painless loss of “central vision” reports straight lines appear curved
 Periphery is preserved
 Leading cause of blindness in the elderly and more common in smokers
Treatment:
 Give Amsler grid or refer to ophthalmologist if Amsler grid is not an option

Retinal Detachment:
Symptoms:
 Sudden onset of floaters
 Looking through the curtain
 Flashes of light
 Painless
Treatment:
 20

 ER STAT

Dacryocystitis
Background:
 Infection of lacrimal sac/tear duct usually caused by blockage
 Common in infants, adults over 40 also have higher risk of developing
Symptoms:
 Thick eye discharge, pain, redness/swelling/warmth of lower eyelid, watery
eye/excess tearing
Treatment:
 Lacrimal sac massage (downward toward mouth) 2-3 times daily; systemic
antibiotics 7-10 days

Allergic Rhinitis:
Background:
 Inflammatory changes of nasal mucosa due to allergies
 Atopic family history (asthma, eczema)
 May have seasonal or daily symptoms
Symptoms:
 Chronic nasal congestion with clear mucus discharge or post nasal drip
 Itchy nose
 Frequent sneezing
 Coughing worsens when supine due to post nasal drip
 Blue-tinged or pale boggy (spongy) nasal turbinate’s
Treatment:
 First Line:
o Nasal steroid sprays (Fluticasone – Flonase) BID, triamcinolone (Nasacort
Allergy) 1-2 sprays QD
 Antihistamine
o Azelastine (Astelin) QD-BID
 Decongestants
o Pseudoephedrine PRN. Avoid in infants and children
 Avoid triggers

Epistaxis (Nosebleed):
Background:
 Anterior nosebleed more common. Caused by bleeding at Kisselbach’s plexus
Treatment:
 Have the pt. blow their nose first
 Apply two sprays of topical nasal decongestant (Afrin). Pinch alae tightly against
nasal septum and hold for 10 minutes

Meniere’s Disease:
Symptoms:
 These three are the classic Meniere’s triad
 21

o Vertigo
o Hearing loss
o Tinnitus
Mnemonic:
VAST
o Vertigo (Episodic)
o Aural (auditory) fullness
o Sensorineural Hearing Loss (Fluctuating)
o Tinnitus (Subjective)
Treatment:
 Usually, self-limiting. Treat acute attacks
 Antihistamines for vertigo
o Meclizine, dimenhydrinate
 Antiemetics for nausea/vomiting
o Promethazine, prochlorperazine

Acoustic Neuroma (Vestibular Schwannoma):

Symptoms:
 Ages 30-60
 Gradual onset, one-sided
 Sensorineural hearing loss, tinnitus that is insidious; CN 8
 Facial numbness and pain if it compresses CN 5
Dx:
 Order an MRI
o Benign tumor of CN 8 causing sensorineural hearing loss and tinnitus. If it
compresses on CN 5 will have facial numbness and pain
Treatment:
 Surgery

Cholesteatoma:
Symptoms:
 Cauliflower
 Foul-smell
 Hearing loss (typically conductive unless it’s way inner than can have
sensorineural)
 If erodes bones in face affects CN VII
Treatment:
 SURGERY

Battle Sign (Basilar Skull Fracture):

Symptoms:
 Parietal bone is most fractured. Linear fracture most common
 “Raccoon eyes”
 Bruising behind the ear (mastoid area) appear within 1-3 days after trauma
 Look for clear, golden serous discharge from the ear or nose
 22

Treatment:
 Refer to ER

Benign Paroxysmal Positional Vertigo (BPPV):

Symptoms:
 Vertigo lasting <1 minute caused by sudden head movements and position
changes
 May lose balance and fall
 Due to calcium carbonate crystals (otoconia) being trapped in the semicircular
canals
Dx:
 Gold Standard: Dix-Hallpike
Treatment:
 Epley Maneuver in clinic or at home by pt
o Test won’t ask how to conduct treatment just be able to associated Epley
with BPPV

Vestibular Neuritis and Labyrinthitis:

Cause:
 Viral infection/Inflammation
Symptoms:
 Sudden/rapid onset of severe vertigo with nausea/vomiting for 1-2 days and then
symptoms lessen
 Sensorineural hearing loss and tinnitus
Treatment:
 Ondansetron (Zofran)
 Methylprednisolone taper

Acute Otitis Media (AOM)(Think of Media for Middle Ear):

Bacteria:
 Streptococcus pneumonia (others: Haemophilus influenza, Moraxella catarrhalis)
o High rate of beta-lactamase resistance
Symptoms:
 Unilateral ear pain (otalgia)
 Popping noises, and muffled hearing
 Either afebrile or low-grade fever
 The tympanic membrane can rupture. Blood and pus can be seen on the pillow
upon awakening with relief of ear pain
 TM will be red. Bulging and the cone of light will be abnormal or displaced
 Most objective finding:
o Decreased mobility per the tympanogram which will be a flat line
Treatment:
 NO antibiotic use in the prior month:
o Amoxicillin high dose (first line): 1000 mg TID x 5-7 days
 Next antibiotic choices are:
 23

o Augmentin x 5-7 days

o Omnicef or cefpodoxime BID x 5-7 days
Penicillin Allergy:
 Type 1 Allergy (anaphylaxis, angioedema):
o Levofloxacin 750 mg QD x 5-7 days OR
o Doxycycline BID x 5-7 days
 Type 2 Allergy (skin rash):
o Omnicef, cefpodoxime, Ceftin BID x 5-7 days
Hearing Tests:
 Conductive Hearing Loss
 Weber- Lateralization to bad ear
 Rinne- BC>AC

Otitis Media with Effusion:

Symptoms:
 Usually, painless
 May follow AOM but can also be caused with chronic allergic rhinitis
 Sterile CLEAR serious fluid is trapped in the middle ear. May see air bubbles
 Ear pressure along with mild hearing loss and ear popping sounds
 TM should NOT BE RED. TM may bulge or retract
Treatment:
 Treat like allergies
 Can do supportive care and wait 3 months
 Oral decongestants
o Pseudoephedrine or phenylalanine
 Steroid nasal spray
o (Fluticasone – Flonase) BID-TID x few weeks or saline nasal spray
(Ocean spray) PRN
Hearing Tests:
 Conductive Hearing Loss
 Weber- Lateralization to affected ear
 Rinne- BC > AC

Otitis Externa (swimmers’ ear):

Bacteria:
 Pseudomonas aeruginosa (gram negative)
 Other: S. aureus- gram positive
Symptoms:
 Erythematous and swollen ear canal that’s tender to touch
 External ear pain
 Purulent green discharge
 Pruritis
 Hearing loss (if blocked with pus)
 History of recent activities that involve swimming or getting ears wet
Treatment:
 24

 Topical steroid and antibiotic combination

o Cortisporin or Cipro HC ear drops QID x 5-7 days
 Keep water out of ear during treatment
 NSAIDs for pain
 If recurrent, can mix solution of alcohol and vinegar ear drops to use after
swimming or when ear canal gets wet
Hearing Tests:
 Conductive Hearing Loss
 Weber- Lateralization to bad ear
 Rinne- BC>AC

Presbycusis:
Symptoms:
 Sensorineural hearing loss without lateralization
 Involves the inner ear
 Symmetrical progression
 Human speech lost first
 Associated with AGING ADULT
 High frequency

Acute Bacterial Rhinosinusitis (ABRS):

Bacteria:
 Streptococcus pneumoniae, H. influenzae, Viral
Symptoms:
 Persistent URI symptoms for 10 days or more or a cold that resolved but
symptoms returned
 Unilateral facial pain/pressure or a toothache (upper molar pain) with nasal
congestion
 Purulent nasal and/or postnasal drip (may have a cough when supine)
o Frontal sinusitis:
■ Frontal headache or headache behind one eye
o Maxillary sinusitis:
■ Facial pain and upper molar tooth pain
Transillumination:
 Compare each side. Affected side may be duller or smaller
Treatment:
 Either immediate antibiotic treatment or observation
 First Line:
o Augmentin 2000 mg/125 mg BID x 5-7 days
 Symptom relief:
o Saline irrigations, nasal steroids, NSAIDs for pain
o Do not use antihistamines or decongestants
Penicillin Allergy:
 Levofloxacin 750 mg QD x 5-7 days or
 Doxycycline BID x 5-7 days
 25

Infectious Mononucleosis:
Cause:
 Epstein Bar Virus (Herpes Virus Family)
Symptoms:
 Sore throat with tonsillitis. May have whitish tonsillar exudates
 Posterior lymphadenopathy
 Severe fatigue present for many weeks
 Maculopapular rash
 Hepatomegaly and or splenomegaly
 Classic Triad:
o Fever
o Pharyngitis
o Lymphadenopathy
Dx:
 Monospot (heterophile antibody)
Treatment:
 Symptomatic
 Rest
 Avoid contact sports and heavy lifting for at least 4-6 weeks. A Ruptured spleen
is a rare but serious sequela of mono
 May do an abdominal US to clear patient for sports

Test Tip: If the patient has strep throat and mono, avoid using Amoxicillin as the antibiotic of
choice. The patient may develop a rash with this drug. Macrolides are a good option
(Clarithromycin). Levofloxacin works as well but it is overkill

Oral Leukoplakia:
Symptoms:
 White colored thick patch found inside the mouth on the cheeks, gums, and
tongue
 It is usually painless
Treatment:
 Refer to ENT for biopsy to rule out cancer of the tongue

Sialolithiasis (aka Whartons duct):

Symptoms:
 Painful lump located in submandibular gland area
 Hurts more with eating due to increased salivation
 Aka calculi or salivary stones

Aphthous Stomatitis (Canker Sores):

Symptoms:
 Painful shallow ulcers that heal in 7-10 days
 Found on the tongue and/or cheeks
Treatment:
 26

 Magic mouthwash

Strep Throat:
Cause:
 Group A streptococcal bacteria (Streptococcus pyogenes)
 Most common cause of sore throat is viral (rhinovirus, adenovirus, RSV)
 Strep is most common in school-aged children
Symptoms:
 Abrupt onset of fever, sore throat, and pain on swallowing
 Absence of viral symptoms (coryza, cough, hoarseness, runny nose, watery eyes)
 Tender anterior cervical lymphadenopathy
 Scarlatiniform rash (sandpaper rash)
 Children:
o May have abdominal pain and diarrhea
Dx:
 Rapid antigen detection test (RADT), throat culture, NAAT testing
Centor Criteria:
 Be able to connect Centor Criteria with Strep Throat
o Fever (1 point)
o Anterior cervical lymphadenopathy (1 point)
o Tonsillar exudate (1 point)
o Absence of cough (1 point)
o Age 3-14 (1 point)
o Age 15-44 (0 points)
o Age >44 (-1 point)
■ Score of 0-1 unlikely need to test for strep; score of 3-4 confirm
with rapid strep test
Treatment:
 Symptoms will start to resolve within 1-3 days once antibiotics are started
 First-Line:
o Penicillin V 500 mg BID to TID x 10 days
 Children:
o Penicillin V or amoxicillin suspension immediate/extended release QD x
10 days
 Anaphylaxis history:
o Macrolides (Z-Pack), Clindamycin
Complications:
 Nonsuppurative:
o Rheumatic fever, scarlet fever, acute poststreptococcal glomerulonephritis,
poststreptococcal reactive arthritis (develops within 1 month after strep)
 Suppurative (Pus):
o Tonsillopharyngeal abscess, cellulitis, OM, sinusitis

Tonsillopharyngeal Abscess:
Symptoms:
 27

 Deviated uvula with a red mass on area of the tonsils

 Pt. will have a high fever, a severe sore throat, dysphagia, and pain with
swallowing
Treatment:
 Refer to ER STAT
 Avoid airway compromise

AV (arteriovenous) nicking- is caused by the arteriole pressing down a retinal vein as a result
of HTN

Hypertensive Retinopathy:
Symptoms:
 Copper/silver wire arterioles
 AV nicking (mild retinopathy)
 Retinal Hemorrhages
 *Be able to identify a picture

Diabetic Retinopathy:
Symptoms:
 Cotton wool spots (moderate retinopathy)
 Micro-aneurysms
 Neovascularization
 *Be able to identify a picture

Koplik’s Spots:
Symptoms:
 “Clusters of small size red papules with white centers in the buccal mucosa by
lower molars”
 Caused by Rubeola (Measles)
o Rubeola and Koplik’s have an “O”
 Fever, conjunctivitis, coryza, cough
 Morbilliform rash
 28

Sensorineural: Lateralization to good ear. Rinne- AC > BC

Conductive: Lateralization to bad ear. Rinne- BC > AC
Rinne: (1st mastoid, to front of ear, time each area)
Weber: Tuning fork midline. CN 8 (acoustic)

Conductive
W Sensorineural
Outer and Middle
Things you can see:
C S Inner
Things you can’t see:
-Cerumen
-Age (Presbycusis)
-Foreign object
-Loud Music
-Infection
-Meniere’s Disease
BC > AC
AC > BC

AC > BC

Normal = No lateralization

Rinne= AC > BC
 29

Cardiovascular:
Hear Murmurs:
First line diagnostic test for murmurs:
 Gold Standard: Echocardiography (TEE)

MR. ASS (MVP) (Systolic Murmur)

 Occur during S1
 Holosystolic
 Pansystolic
 Early systolic
 Late systolic
 Midsystolic

MR-Mitral Stenosis
AS- Aortic Stenosis
S- Systole
MVP- Mitral Valve Prolapse

Tip: For exam only really need to know timing and location Base

Mitral Regurgitation (holo/pansystolic):

 Radiates to axilla! Apex
 Location:
o 5th intercostal space (ICS) by mid clavicular line (MCL), apex, apical area
 Mitral Valve Prolapse found here as well:
o Symptoms:
■ Usually asymptomatic or may have palpitations, chest discomfort,
dizziness, easily fatigued, SOB, and anxiety. It is more common in
females
o Location:
■ 5th intercostal space (ICS) by mid clavicular line (MCL), apex,
apical area

Aortic Stenosis (mid systolic ejection):

 Radiates to neck!
 Higher risk of sudden death
 Location:
o Aortic area, 2nd ICS by right upper sternum; at the base of the heart by the
right upper sternum; base of heart on the right side of sternum
 30

MS. ARD-e (Diastolic Murmur)

 All diastolic murmurs are pathological (indicate heart disease)
 S2 heart sound
 Early diastole
 Late diastole
 Mid diastole

MS- Mitral Stenosis

AR- Aortic Regurgitation
D- Diastole
e- Erb’s point

Mitral Stenosis (Mid/Late Diastole):

 Soft low rumbling with an opening snap
 Loudest at the apex
 Only murmur you use Bell to auscultate
 Atrial fibrillation common (emboli risk)
 Dyspnea most common symptom
o Exam may ask what type of murmur has dyspnea associated with it
 Location:
o Apex, apical area, mitral area, 5th ICS by midclavicular line

Aortic Regurgitation (Early Diastole):

 Loud high pitched, blowing murmur
 Arterial pulses can be abnormal
 Location:
o Best heart at 3rd and 4th ICS at the left sternal border (Erb’s point)

Heart Murmur Grading System:

 Grade I:
o Barely audible
 Grade II:
o Audible
 Grade III:
o Clearly audible
 Grave IV:
o First time thrill is present (more than likely will ask for this on exam)
 Grade V:
o Hear the murmur even with edge of stethoscope off
 Grade VI:
o Murmur is so loud that it can be heard with entire stethoscope off chest
 31

Benign Split S2:

 Best heard over pulmonic area (2nd ICS left side of sternum)
 Normal finding:
o Appears during inspiration and disappears with expiration

S3:
Associated with HF
Sounds like “Kentucky”
Occurs in early diastole
Abnormal in ages >35
Normal finding during pregnancy, young children, and some athletes
Use Bell of stethoscope to listen
S4:
Associated with LVH; increased resistance due to stiff left ventricle
Also known as “Atrial kick/gallop”
Sounds like “Tennessee”
Occurs in late diastole
S1:
Closure of AV vales (atrioventricular valves)
S2:
Closure of SL vales (semilunar valves)

Mnemonic:
Motivated (S1 heart sound-lub) Apples (S2 heart sound-dub)
M (mitral valve) A (aortic valve)
T (tricuspid valve) P (pulmonic valve)
AV (atrioventricular valves) S (semilunar valves)

Mitral Valve Prolapse (MVP):

 S2 click, followed by a late systolic murmur
 Pt is typically asymptomatic or may have palpitations, chest discomfort,
dizziness, easily fatigues, SOB, and anxiety. It is more common in females
 MVP with palpitations is treated with beta-blockers (BB)

Isolated systolic hypertension:

 A systolic >140 with a diastolic <90
Treatment:
 Thiazide diuretic or CCB

Medications that cause heart burn:

 CCB, BB, alpha agonists (HTN meds)
 32

Atrial Fibrillation (AF) (Most common arrhythmia in the US)/ Atrial Flutter:
Symptoms:
 Can be paroxysmal or persistent
 Pt. will complain of the sudden onset of heart palpitations accompanied by
weakness, dizziness, fatigue, and dyspnea
 May have chest pain and feel like passing out
 Rapid and irregular pulse which may be greater than 110 per minute with
hypotension
Dx:
 Diagnostic test is 12 lead ECG which won’t show discrete P waves and will be
irregularly irregular
Treatment:
 Refer to cardiology for medical management
 Evaluate the need for antithrombic therapy
o CHA2DS2-VASc
■ Be familiar with what each letter stands for on the exam and
what a score of >2 means
 C-CHF

 A2-Age ≥75
 H-Hypertension

 D-Diabetes
 S2-Stroke/Transient ischemic attack (TIA)
 V-Vascular disease
 A-Age 65-74
 S-Sex; female gender is at a higher risk
o Score of 0 is low risk
o Score of 2 or more requires anticoagulation
o A2 and S2 give the pt’s 2 points right away
 Avoid stimulants (caffeine, nicotine, decongestants), and alcohol
 Rate control with CCB, BB, and digoxin

Anticoagulation:
Factor Xa inhibitors (direct thrombin inhibitors):
 No regular blood test or dietary restrictions
 Do not use if the patient has valvular abnormality (should use Warfarin instead)
 Drugs:
o Dabigatran, Rivaroxaban, Apixaban
 Drug interactions:
o Antacids, H2 blockers, PPI’s (stomach medication)
 Increased bleeding risk:
o NSAIDs, clopidogrel
 33

Warfarin sodium (Coumadin):

 For valvular and non-valvular atrial fibrillation
 Dosing based on INR
 Takes about 2-3 days for INR to change and anticoagulant effect takes 2-3 days to
occur
 Warfarin is a vitamin K antagonist (category X)
 Avoid vitamin K rich foods as it will DECREASE the INR
o Green leafy vegetables, broccoli, Brussel sprouts, cabbage, mayonnaise
 Drug Interactions:
o Sulfa drugs (Bactrim), Macrolides (Erythromycin), NSAIDS (Ibuprofen)
these INCREASE the INR

Anticoagulation Therapy Goal (INR 2-3):

Atrial fibrillation, DVT:
 2-3
Synthetic/Prosthetic valve:
 2.5-3.5
Duration:
 First episode of provoked (surgery)/unprovoked venous thromboembolism:
o Minimum 3 months
 Indefinite anticoagulation:
o Recurrent VTE, VTE with persistent, irreversible, or multiple major risk
factors, unprovoked isolated distal DVT, etc.

Paroxysmal Supraventricular Tachycardia:

Causes:
 Digoxin toxicity, alcohol, hyperthyroidism, caffeine intake, illegal drugs, etc.
Symptoms:
 ECG shows tachycardia, PEAKED QRS complex with P waves.
 Wolff Parkinson White (WPW) Syndrome, common in kids
 Heart rate 150-200 bpm with palpitations, SOB, anxiety, etc.
Treatment:
 If ECG shows WPW or pt is symptomatic refer to cardiologist for possible
cardioversion or call 911
 Vagal maneuvers, if carotid massage needed refer to cardiologist
o Carotid massage is contraindicated with a history of a TIA or stroke in
the past 3 month, or if the patient has a carotid bruit

Pulsus Paradoxus:
Definition:
 A decrease in systolic BP of > 10 mmHg during INSPIRATION
 An important physical sign of cardiac tamponade
Causes:
 Cardiac tamponade, pericardial effusion, acute MI, constrictive pericarditis
 34

 Asthma, tension pneumothorax, emphysema

Symptoms:
 Pulmonary and cardiac conditions that impair diastolic filling can cause an
exaggerate decrease of the systolic pressure of more than 10 mmHg

Orthostatic Hypotension:
Background:
 A decrease in the systolic BP of at least 20 mmHg or the diastolic BP of at least
10 mmHg within 3 minutes upon standing
Symptoms:
 The patient can be asymptomatic or may have
 Lightheadedness
 Dizziness
 Tachycardia
Dx:
 Supine to standing BP

Infective Endocarditis (Bacterial Endocarditis):

Symptoms:
 Fever
 Chills
 Malaise
 New onset murmur
 Osler’s nodes- painful petechiae, violet-colored nodes on the finger pads or toes
 Non-blanching reddish lines in nailbed (Splinter hemorrhage)
 Janeway lesions- non tender red spots on the palms/soles
 Fundoscopic exam may show Roth spots or retinal hemorrhages
Dx:
 Blood culture x3 (first 24 hours)
 TEE
Treatment:
 Refer to cardiologist or ER for hospitalization and IV antibiotics
Endocarditis Prophylaxis:
 Recommended for high-risk conditions and invasive procedures
o Prosthetic heart valves (includes bioprosthetic and homograph valves)
o History of infective endocarditis
o Cyanotic congenital heart diseases
o Heart failure
o Cardiac transplant with valvulopathy
o Procedures that can cause bleeding/trauma to tissue
■ Dental work (tooth cleaning, tooth extractions), tonsillectomy,
adenoidectomy, bronchoscopy with biopsy or any invasive
respiratory tract procedure
■ TEE
 First Line:
 35

o Amoxicillin 2 g (children 50 mg/kg) 1 hour before procedure

 Penicillin Allergy:
o Clindamycin 600 mg, clarithromycin 500 mg or cephalexin 2 g
Abdominal Aortic Aneurysm (AAA):
Risk:
 Highest risk 70-year-old elderly White male who is a smoker (current or quit) and
has HTN
Symptoms:
 Most patients are asymptomatic
 If the AAA has not ruptured symptoms include abdominal, back, or flank pain
 Severe, sharp excruciating pain with a pulsatile abdominal mass occurs in 50% of
patients
 Signs and symptoms of shock
 Acute and sudden onset of “tearing” severe low-back/abdominal pain
 AAA may be found incidentally on a chest or abdominal x-ray
Dx:
 Initial imaging is Ultrasound
Treatment:
 Refer to ER

Coarctation of the Aorta:

Background:
 Normally SBP is higher in the legs than the arms.
 If patient has coarctation of aorta the SBP is higher in the arms than legs.
Symptoms:
 Pulses in legs won’t be palpable
 The radial pulse will be bounding
 The BP will be high
 A heart murmur may be present
Dx:
 Echo, ECG, cardiac MRI or cardiac CT

Hypertension (HTN):
Definition:
 BP above 130/90
Risk:
 Major risk factor for stroke, MI, vascular disease and chronic kidney disease
Rule out secondary HTN:
 Most common cause is renovascular conditions (narrowing of the rental artery)
Blood Pressure Stages:
 36

ACC/AHA SBP mmHg DBP mmHg

Norma <120 and <80
l 120-129 and <80
Elevate 130-139 or 80-89
d Stage 140 or higher or 90 or higher
1
Stage 2

JNC8 SBP mmHg DBP mmHg

Norma <120 and <80
l 120-139 or 80-89

≥ 160 ≥ 100
Prehypertension 140-159 or 90-99
Stage 1 or
Stage 2

Test Tip:
 Stage 1 (140-159/90-99)
o Knowing this number will help with everything else
o Normal is <120/80
o Elderly over 60
■ 150/90 is ok
■ Isolated systolic HTN will increase systolic not diastolic
o Goal BP for most patients:
■ <130/80 mmHg

ACC/AHA Recommendations:
 Lifestyle is first line treatment
o Weight loss
o Heart healthy diet (DASH)
o Dietary sodium restriction
o Increase dietary potassium
o Reduce alcohol intake (women 1 serving; men 2 servings per day)
o Structured exercise program (150 minutes aerobic activity per week)

TEST TIP:
 If Goal BP is not reached at 1 month, increase the dose on the initial drug and/or
add a second drug

Hypertension Meds:
 African-American with or without diabetes:
o Initial choices include thiazide diuretics or CCBs
 Non-Black with or without diabetes:
o Initial choices include thiazide diuretics, CCBs, ACEIs, or ARBs
 Thiazide diuretic “ide”:
o Excellent synergist
o Do not give to patient with a Sulfa allergy
 37

o Favorable in osteopenia/osteoporosis patients (elderly females)

o Side effects include:
■ Hyperglycemia (avoid in diabetics)
■ Hyperuricemia (gout attack/contraindication)
■ Hypertriglyceridemia and hypercholesteremia (check lipid profile)
■ Hypokalemia
■ Hyponatremia
■ Hypomagnesemia
■ Lowers BP only 2-8 points
 ACE inhibitor – “pril” and ARB – “sartan”:
o Use in high renin states
o Drug of choice in diabetics (protects kidneys)
o Pregnancy category C/D
o Side effects include:
■ Dry/hacking cough (more with ACE)
■ Hyperkalemia
■ Angioedema (rare, life-threatening)
■ Contraindicated in moderate to severe kidney disease
■ Do not use ACE and ARB together
 Beta blocker “olol”:
o Good as add-on medication
o Used for uncomplicated HTN
o Avoid abrupt discontinuation, wean slowly to avoid rebound HTN or an MI
o Contraindications include:
■ Asthma, COPD, chronic bronchitis, emphysema, 2nd and 3rd heart block
(okay with 1st degree), sinus bradycardia
■ Do not use Propranolol for HTN
 Calcium channel blocker “pine”:
o First choice for ISH (isolated systolic HTN) if thiazide is not an option
o Side effects include:
■ Headaches (vasodilation)
 38

■ Ankle edema (vasodilation; benign)

■ Heart block/bradycardia (depresses cardiac muscle and AV node)
■ Reflex tachycardia (nifedipine)
■ Contraindicated in:
 2nd and 3rd degree heart block, bradycardia, and CHF

Heart Failure:
 ACE or ARB as first line, plus BB, plus diuretic. First line will be ACE inhibitor on exam
after diuretics to relive symptoms of volume overload
DM:
 ACE or ARB first line
 If (African American) AA start with CCB or Thiazide
CKD:
 ACE or ARB first line, can add CCB or Thiazide
Stroke Hx:
 ACE or ARB first line, add CCB or Thiazide as second line drugs
AA even if pt. has DM:
 Thiazides and CCB
Bilateral Renal Artery Stenosis:
 ACE and ARB will WORSEN or cause acute renal failure and are contraindicated

PAD/ PVD (same condition):

Symptoms:
 Patient complains of worsening pain on ambulation (intermittent claudication)
that is relieved by rest
 Atrophy, shiny, hairless and dry skin that is cool to the touch
 Gangrene on one or more toes
 Nocturnal pain relieved by lowering legs
 Poor pulses (increased capillary refill time)
Dx: SBP of each ankle
ABI= SBP upper arms (use higher BP)
 Initially do a pulse check
 ABI 0.9 or less is PAD/PVD
 Arteriography is the most DEFINITIVE test but on exam most likely answer will
be ABI
 Try to develop collateral circulation (exercise by walking daily)
 Avoid support stockings (compression therapy)
 39

CVI (Chronic Venous Insufficiency):

Symptoms:
 Impaired venous return
 Achy legs relieved by elevation
 Edema after prolonged standing
 Hyperpigmentation
 Night cramps
 Brownish discoloration, cold, ulcers
 Pulses are palpable
 Varicose veins, spider veins in lower extremity
Dx:
 Venous duplex US
Treatment:
 Support stockings (compression therapy)
 Elevate both legs to decrease swelling

Raynaud’s Phenomenon:
Symptoms:
 More common in females
 Recurrent episodes of cold, numb, and painful fingertips and/or toes
 Triggered by cold weather and/or stress
 Change color (white, blue, red) which resolve spontaneously
 Higher risk of autoimmune disorders
Treatment:
 Calcium channel blocker (nifedipine, amlodipine)
 Avoid cold weather and handling cold objects
 Stop smoking
 Wear gloves and wear warm clothes in cold weather

Acute Decompensated HF:

Symptoms:
 Dyspnea and exertional dyspnea
 Edema
 Hepatic congestion
 Epigastric/abdominal tenderness
 Rales
 Nocturia
 Elevated JVD
Dx:
 B-type natriuretic peptide (BNP)
o On exam
 Chest x-ray
o Enlarged heart, interstitial edema (pulmonary edema)
Treatment:
 Look at the cause of the HF
 40

 Refer to ER

Left Sided Heart Failure = Lungs

Physical Exam:
 S3, crackles, decreased breath sounds, wheezing
Right Sided Heart Failure = GI
Physical Exam:
 JVD, enlarged liver, enlarged spleen

New York Heart Association (NYHA) Function Capacity:

 Class I:
o NO limitations
 Class II:
o Ordinary activity results in fatigue and dyspnea Symptoms 1st appear
 Class III:
o Marked limitation with NORMAL activity
 Class IV:
o Symptoms at REST or with any physical activity

Acute Myocardial Infarction (Acute Coronary Syndrome):

Symptoms:
 Heavy pressure/tightness on the chest that radiates to the left shoulder and neck
and/or jaw (left side) OR
 New onset of angina that markedly limits physical activity OR
 Rest angina that lasts more than 20 minutes
 Diaphoresis
 Shortness of breath
 Nausea and Vomiting
 Palpitations
Dx:
 ECG
Treatment:
 Call 911 and start CPR or use AED if needed
 Give aspirin dose of 162-325 mg to chew and swallow
 Should start a BB after having a MI reduces cardiac oxygen demand, is
cardioprotective, and limits cardiac remodeling

BMI chart:
BMI:
18.5- 24.9 Normal
BMI:
25-29.9 Overweight
BMI:
30 or > Obese
 41

Hypercholesteremia:
Lipid Profile:
 Total Cholesterol <200 mg/dL
 Triglycerides <150 mg/dL
 LDL <100 mg/dL
 HDL > 40 mg/dL (men) >50 mg/dL (women)
When triglycerides are extremely elevated, the goal is to lower then first to prevent
pancreatitis before the high LDL with fibrates (fenofibrate, gemfibrozil, bezafibrate)

Rhabdomyolysis:
Background:
 Breakdown of muscle tissue (myoglobins) which are toxic to the kidney (acute
renal failure)
Symptoms:
 New onset of severe muscle fatigue, weakness, or local pain
 Dark colored urine (cola color)
 History of statin use
Labs (Rhabdomyolysis):
 Creatine kinase (CK)
 Creatinine (acute renal failure)
 Urinalysis (myoglobinuria)
Treatment:
 Hold statin and hydrate
 Order LFT, creatine kinase, creatinine, serum potassium

Statin Therapy:
 Must check LFT before starting Statin (HMG-CoA Reductase Inhibitors)

High Intensity Statin:

 Atorvastatin (40-80 mg) and Rosuvastatin (20-40 mg)
o Start low and go slow
Give High Intensity to:
 Age <75
 Have a Cardiac or Brain issue
 Or their LDL ≥ 190 mg/dL without ASCVD
Give Moderate Intensity to:
 Age 40-75
 No ASCVD or DM
 10-year ASCVD risk ≥ 7.5%
Give Moderate Intensity to:
 Age 40-75
 Or Age >75 and not a candidate for high intensity
 DM
 LDL 70-189 mg/dL
 42

Metabolic Syndrome (Insulin Resistance Syndrome or Syndrome X):

Criteria:
 Presence of at least 3 of the 5 conditions
Symptoms:
 Abdominal obesity >40 inches in men; >35 inches in women
 Hypertension BP >130/85 mmHg
 Elevated fasting plasma glucose >100 mg/dL
 Elevated triglycerides >150 mg/dL or on drugs to treat condition
 Decreased HDL <40 mg/dL in men and <50 mg/dL in women
Risk:
 Higher risk for type 2 diabetes and CV disease, non-alcoholic fatty liver disease
 43

Pulmonary:
Pulmonary Emboli (PE):
Cause:
 Most common cause is a DVT
Symptoms:
 Sudden onset of dyspnea and cough
 Cough may be productive (pink-tinged)
 Tachycardia, pallor, and the feeling of impending doom

Anaphylaxis:
Type:
 IgE mediated reaction
Treatment:
 Give epinephrine 1:1000 (1 mg/ml) IM or subcutaneous first before calling 911
unless another person is available to help. The second person should call for help
while NP is giving epinephrine

Auscultation:
Base/Lower lobes: vesicular breath sounds
Bronchi/upper airway: bronchial to bronchovesicular

Percussion:
Resonant: normal
Dull: lobar pneumonia
Dull: over ribs/bones, liver, heart
Hyper-resonant/tympany: emphysema

Lung Cancer Screening:

 Adults aged 50-80 (20 pack year history) who currently smoke or quit within the
past 15 years
 Annual screening with low-dosed helical computed tomography (helical CT scan)

Identify a pack year:

 Multiply number of packs smoked per day with number of years the person
smoked
o Ex (smoked 1 pack per day for 1 year)= 20 cigs/day x 1 year = 1 pack year

Spirometry:
 Helps to diagnose COPD
 FEV1 <80% of predicted
 FEV1/FVC ratio <0.7 is diagnostic for COPD
o #1 risk factor for COPD is chronic smoking
 44

COPD Medications:
 ICS: inhaled corticosteroids (fluticasone, budesonide)
 SABA: short-acting beta-agonist (albuterol, levalbuterol/Xopenex)
 LABA: long-acting beta-agonist (formoterol, salmeterol, formoterol)
 SAMA: short-acting muscarinic antagonist or short-acting anticholinergic (ipratropium
bromide/Atrovent
 LAMA: long-acting muscarinic antagonist (tiotropium/Spiriva)

COPD Treatment 2020 GOLD Guidelines:

Group A:
 SABA or SAMA/Anticholinergic combo
 For the EXAM ANTICHOLINERGICS are FIRST line for COPD
Group B: that are poorly controlled:
 LAMA or LABA
 May use SABA for rescue PRN
Group C:
 LAMA first line
 If poorly controlled use LAMA plus LABA
 Alternative is LABA + ICS
 SABA for symptom relief PRN
Group D:
 Refer
 LAMA-LABA combination

COPD long term treatment for survival is OXYGEN when the patient has chronic hypoxemia

Chronic bronchitis:
Symptoms:
 Type of COPD that is characterized by inflammation of the bronchi, causing
excess mucus
 Characteristics include a diagnosis after age 35, obesity, copious amounts of
purulent sputum, elevated HCT level
 A productive cough that lasts at least 3 months with recurring bouts for at least 2
consecutive years
Treatment:
 Treat with SABA (albuterol), inhaled anticholinergics (ipratropium)
Risk:
 Secondary bacterial infections (H. influenzae pneumonia)
o Symptoms:
■ Acute onset of fever, more purulent sputum, increased wheezing,
dyspnea and fatigue
o Treatment:
■ Bactrim, Doxycycline, or Ceftin BID x 10 days
 45

■ If more severe use Augmentin or respiratory quinolone (Levaquin)

x 3-7 days

Emphysema:
Symptoms:
 Percussion-HYPERENNOSANCE
 Tactile fremitus- decreased
 Egophony- decreased
 Accessory muscle use
 Pursed-lip breathing
 Weight loss
Dx:
 CXR:
o Flattened diaphragm with hyperinflation
o Increased AP diameter

Pneumococcal Vaccine:
 PPSV 23 (pneumococcal polysaccharide vaccine or Pneumovax) given to elderly
 PCV 13 (pneumococcal conjugate vaccine or Prevnar) started out with kids
 Age 65 or order:
o Give PCV 13 (Prevnar) or PPSV 23 at least one year apart
 If patient is at risk, they may have received PPSV 23 at a younger age (if given
<65, give again after 5 years)

CURB65:
 Used to determine if outpatient treatment for pneumonia is appropriate or if the
patient should be hospitalized
 You will have an exam question on this
o C-Confusion (1 point)
o U-Urea (BUN >19 mg/dL) (1 point)
o R-Respiratory Rate >30/minute (1 point)
o B-BP (systolic <90 or diastolic <60 mmHg) (1 point)
■ If score is 1 or less outpatient is appropriate
■ If >1 hospitalize patient

Community-Acquired Pneumonia (CAP):

Bacteria:
 Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae,
Moraxella catarrhalis
Symptoms:
 Acute onset of fever/chills with a productive cough and pleuritic chest pain
 Phlegm is yellow, green to rusty-color
Physical Exam:
 Crackles/rales, wheezing, bronchial sounds
 46

 Positive tactile fremitus, egophony and whispered pectoriloquy (whispered words

easily heard on lower lobes)
 Dullness to percussion
Labs:
 Gold Standard: Chest x-ray (reveals consolidation usually in the right middle
lobe on exam)
 ATS/IDSA does not recommend gram stain, sputum C&S, or blood cultures in
CAP patients
 WBC >11.0
 Elevated neutrophils >70%
 Shift to the left seen with bacterial infections
 Band cells; immature WBC’s
Empiric Treatment:
 No comorbidities or risk factors for MRSA or Pseudomonas aeruginosa
 Healthy, age <65, no recent antibiotic use
o Amoxicillin 1 g TID PLUS a macrolide (azithromycin, clarithromycin) or
■ Doxycycline 100 mg BID
o Penicillin Allergy (IgE reaction):
■ 3rd generation cephalosporin (cefpodoxime/Vantin)
Comorbidities Present:
 Chronic heart, lung, liver, asplenia, renal disease, DM, HTN, etc.
o Respiratory Fluroquinolones (monotherapy)
■ Levofloxacin (Levaquin) 750 mg daily
■ Moxifloxacin (Avelox) 400 mg daily
■ Gemifloxacin (Factive) 750 mg daily
Suspect P. aeruginosa CAP:
 Use ciprofloxacin BID

Atypical Pneumonia:
Bacteria:
 Mycoplasma pneumoniae, chlamydia pneumoniae
Symptoms:
 Fever, malaise, cough, some SOB, rales, rhonchi, and/or wheezes
 Usually mild and most patients recover without complications
 Cough may be prolonged (median 21 days)
Labs:
 Chest x-ray (usually non-specific, can resemble viral pneumonia)
o Do not need CXR in atypical pneumonia
o CBC with diff
■ WBC: normal or mildly elevated
o PCR based assay or NAAT (nasopharyngeal swab, sputum)
Empiric Treatment:
 Macrolides (Azithromycin- Z-Pack) or Clarithromycin BID
 Doxycycline 100 mg BID
 47

Asthma:
Background:
 Chronic airway inflammation which results in hyperresponsive airways and
bronchoconstriction which is reversible
Symptoms:
 Increased frequency of using albuterol inhaler without relief
 Complains of chest tightness, cough especially at night
 Unable to speak in full sentences due to SOB
Treatment:
 See full guidelines below
 Rescue drug: SABAs 1-2 inhalations QID PRN
o Albuterol, levalbuterol (Xopenex)
 Controller Medication: Inhaled corticosteroids (first line)
o Fluticasone (Flovent HFA), flunisolide (Aerobid) 2 puffs BID
Asthma Meds: Safety Issues:
 Inhaled/Oral corticosteroids: osteoporosis, cataracts & glaucoma
 Oral thrush: (rinse mouth out with water after using steroid inhaler)
 Salmeterol/Formoterol: increase risk of death, pneumonia
 Albuterol: arrhythmias, angina, MI

Asthma Classification (age 12 years and older):

Exam Tip:
Memorize Step 2 and you will be able to get the others

Asthma Severity Symptoms Nighttime Awakenings Peak Expiratory Flow or FEV1

Step 1 < 2 days per week <2x per month > 80% of expected
Intermittent

≥ 80%
SABA <2x per month
Step 2 >2 days per week 3-4x per month
Mild Persistent
SABA >2x per week
but not daily
Step 3 Daily attacks (may >1 night per week but 60-80%
Moderate Persistent last for days not nightly

SABA use daily

Asthma (2007 GINA guidelines):

1. Intermittent (SABA PRN)
-butrol
2. Mild persistent (Low-dose ICS)
-ide; -sone
3. Moderate persistent (Low dose ICS + LABA or Medium-dose ICS)
 48

-meterol
4. Moderate to severe persistent (Medium dose ICS + LABA)

Asthma (2020 GINA guidelines):

1. Intermittent (Low dose ICS-formoterol PRN)
a. Alternative: Low dose ICS with SABA
2. Mild persistent (Low dose ICS daily or low dose ICS-formoterol PRN)
3. Moderate persistent (Low dose ICS-LABA daily or medium-dose ICS or low dose ICS+
LTRA)
4. Refer

AANP has been testing on the 2007 GINA guidelines however, should be familiar with both

BASCIALLY IF LOW DOSE ICS, NEXT IS MEDIUM DOSE ICS ON EXAM

Intermittent
(<2 days, <2 nighttime, <2 SABA per month)
SABA

Mild persistent
(>2d, 3-4 nighttime per month, SABA >2x not daily)
SABA, Low dose ICS

Mod Persistent
(DAILY, NOT NIGHTLY)
SABA, Low dose ICS plus LABA or Medium dose ICS

Always think first line treatment for asthma is some type of SABA, and ICS

Urgent/Emergent Care of Asthma:

 Treat with repetitive or continuous SABA
o MDI or nebulizer (3 times in total)
 Give oral systemic corticosteroids in moderate or severe exacerbations
o Give 3-5 days of oral steroids
o Longer than 5 days will have to taper
 Monitor response:
o Repeat PEF and pulse oximetry, recheck lungs, respiratory rate, and pulse
 If PEF is 50% or less of expected, pulse oximetry SpO2 of 91 or less after
treatment; call 911

Categorize asthma control into three categories:

Well controlled (PEF/FEV1 at 80% or more) of predicted or personal best value
Not well controlled (60 to 80%) of predicted or personal best value
Very poorly controlled (<60%) of predicted or personal best value
 49

What are the variable used to figure out the PEF (peak expiratory flow)?
 Height, Age, and Gender
o Mnemonic: HAG

Tuberculosis:
Symptoms:
 Fatigue
 Fever
 Cough
 Usually in the upper lobes
Dx:
 Gold Standard: Sputum for C&S
 Should order NAAT and AFB in addition
 CXR will show cavitations or “black holes”
 If ACTIVE TB is suspected order, NAAT, C&S, and AFB. The AFB is not
diagnostic. Deep morning cough collected for three “consecutive days”
Treatment:
 Never do fewer than 3-5 drugs initially if positive, then can narrow it down
 Latent TB usually treated with rifamycin
 Reportable disease
Tb Skin testing:
 Highest risk:
o >5 mm positive if immunocompromised or person has been in close
contact
 High risk (biggest category):
o >10 mm positive if recent immigrants, working class, drug users,
individuals exposed at home
 Low risk:
o >15 mm positive for individuals who have no risk factors
 50

Endocrine:
Thyroid Gland:
 Secretes triothyronine (T3) and thyroxine (T4) in response to thyroid stimulating
hormone (TSH) which is made by the anterior pituitary gland
 The hypothalamus regulates TSH production (negative feedback)
 Thyroid hormones regulate the metabolic rate in adults and brain growth in
infants

Parathyroid glands (4 glands):

 Produces parathyroid hormone (PTH) which regulates calcium blood levels
 Two parathyroid glands behind each lobe

Parathyroid gland:
Background:
 PTH is responsible for calcium loss or gain from bones, kidneys, and GI tract
Dx:
 Will have elevated calcium because your parathyroid is releasing too much
calcium from bones
Treatment:
 Bisphosphonates for secondary hyperparathyroidism

Primary Hyperparathyroidism:
 High levels of serum calcium
 Patient is usually asymptomatic

Hypothyroidism:
Cause:
 Most common cause Hashimoto’s Thyroiditis (chronic autoimmune disease)
o Hashimoto and Hypo both have an “O”
Risk Factors:
 Family history, post-partum period, history of autoimmune disease, and females
>50 years old
Screening:
 TSH (normal value 0.4-4.0 mU/L)
 Abnormal TSH >5.0 mU/L on exam
Symptoms:
 Lethargy, fatigue, weight gain, cold intolerance, decreased memory, dry skin
 Amenorrhea to irregular menstrual cycle
 Hair loss (alopecia) outer 1/3 of eyebrows
 Delayed relaxation phase of deep tendon reflexes (DTR)
 Diffusely enlarged thyroid (goiter) to normal gland without nodules
Dx:
 High TSH, Low T4, low or normal T3
 51

 However, Free T4 is much more specific for this disease

 Hashimoto’s (autoimmune) disease everything in the body slows down
Treatment:
 Synthroid
o Start low and go slow (25-50 mcg) on an empty stomach
■ Can cause cardiac side effects
o Check TSH every 6-8 weeks to monitor treatment response
o Lithium can damage the thyroid resulting in hypothyroidism. Check TSH
and the kidneys at least once a year

Hyperthyroidism (Thyrotoxicosis):
Cause:
 Most common cause is Grave’s Disease (autoimmune)
 Secondary cause is toxic multi-nodular goiter
 Grave’s and Hyper both have an “R”
Symptoms:
 Lid lag
 Exophthalmos (bulging eyes)
 Anxiety
 Tachycardia
 Heat intolerance
 Everything is Hyper within the body
 Thyroid goiter and or nodules on goiter
 Keep an eye out for Thyroid Storm (thyrotoxicosis)
o Acute worsening of symptoms. May be caused by stress or infection. Look
for LOC, fever, abdominal pain; life-threatening; immediate
hospitalization needed
Screening:
 TSH (normal value 0.4-4.0 mU/L)
 Abnormal TSH <0.5 mU/L on exam
Dx:
 Low TSH; high T4; normal or high T3
Complications:
 Arrythmias (Atrial Fib, PVC’s) angina, CHF, thyroid storm, osteoporosis, death
Treatment:
 PTU/Tapazole is preferred once a day
 Radioiodine ablation
o Destroys thyroid gland resulting in hypothyroidism
 PTU PREFERED IN PREGNANCY. Do not used radioactive iodine uptake
(RAIU) in pregnancy

RAIU:
 Don’t give with pregnant patients
 Destroys thyroid, lifelong treatment for hypothyroidism
 52

Cushing’s syndrome:
Symptoms:
 Central obesity
 Moon face
 Purple striae
 Hairy
 Hypertension
Dx:
 Elevated plasma CORTISOL in AM
 “Increased blood sugar, and sodium”
 Decreased potassium (K)
 You must draw cortisol levels in the evening

Addison’s Disease:
Symptoms:
 Craving “salty food”
 Hyperpigmentation
Dx:
 Deficient in cortisol and aldosterone (think LOW sodium, blood sugar)
 Increased K
 You must give cortisol. Draw AM cortisol

Subclinical Hyper and Hypothyroidism:

 If the TSH is >5.0 mU/L but serum-free T4 and T3 are normal the patient has
subclinical hypothyroidism
 If the TSH is <0.5 mU/L but serum- free T4 and T3 are normal the patient has
subclinical hyperthyroidism
o With both conditions recheck TSH in 6-12 months

Condition TSH Free T4 T3

Hypothyroidism >5.0 mU/L Low Low
Subclinical Hypothyroidism >5.0 mU/L Normal Normal
Hyperthyroidism <0.05 mU/L High Higher
Subclinical Hyperthyroidism <0.05 mU/L Normal Normal

Diabetes Mellitus Type 1:

Symptoms:
 Polyphagia
 Polyuria
 Polydipsia
 Weight loss
 Breath may smell like acetone (ketoacidosis)
 53

Diabetes Mellitus Type 2:

Background:
 Progressive deceased secretion of insulin resulting in a chronic state of
hyperglycemia and hyperinsulinemia

Screen for Diabetes:

 Adults aged 45 years and older, all adults with BMI 25 or >, history of GDM
 Additional risk factors to screen:
o Acanthosis nigricans
o HDL 35 mg/dL or Triglyceride level 250 mg/dL or greater
o HTN
o First degree relative with diabetes
o High risk ethnicity (AA, Latino, Native American, Asian, Pacific Islander)
o Hx GDM or women who delivered infants weighing 9 lb. or >

Criteria for Diagnosing Diabetes:

Prediabetes:
1. Fasting plasma glucose- 100-125
2. Random plasma glucose >200 with at least 1 symptom of 3P’s (polyuria, polydipsia,
polyphagia)
3. OGTT- 140-199
4. A1C 5.7-6.4%

 A1C goals 7.0% or less if diabetic

 Check A1C every 3 months until blood glucose controlled or when changing therapy then
twice a year

Hypoglycemia:
Background:
 Pancreas releases glucagon which stimulates your liver to convert stored glycogen
to glucose
 If asks what pancreas secretes besides this its digestive enzymes
Treatment:
 Glucose 15 g for conscious patients
o 4 oz of orange juice, regular soft drink, hard candy
o “15-15” rule. 15 g of carbohydrate and recheck glucose in 15 minutes
 Glucagon:
o For patients at significant risk for severe hypoglycemia which is defined
as a blood glucose <54 mg/dL

If already on TWO oral drugs for diabetes and A1c is 9 or higher, start BASAL insulin
 54

Dawn Phenomenon:
Background:
 Physiologic process (Normal Process)
 Glucose elevated in morning due to growth hormone
Treatment:
 Don’t eat carbs before bedtime
 Take insulin at bedtime (instead of earlier in the evening)
 Increase insulin dose

Somogyi Effect (Rebound Hyperglycemia):

Background:
 Abnormal process
 Caused by too much exercise, skipping nighttime snack, or too much insulin
before bedtime
 Stimulates compensatory secretion of growth hormone, cortisol, epinephrine and
glucagon
 More common in Type 1 Diabetics
Dx:
 Set alarm between 2-3 AM daily for 1-2 weeks. If glucose is <60 Somogyi effect
Treatment:
 Lower bedtime insulin dose
 Change insulin type
 Eat a snack with evening insulin dose

Charcot’s Food and Ankle (Neuropathic Arthropathy):

Background:
 Deformity of the foot that is caused by joint and bone dislocation and fractures
due to neuropathy and loss of sensation to the foot and ankle

Diabetic Treatment:
Type 1 DM:
 Insulin only
Type 2 DM:
 Metformin
o Max out the medication then add others.
o Max dose 2 g of extended release

Type 2 DM with established ASCVD/CAD:

 SGLT-2 (-flozin)
o Canagliflozin, Empagliflozin, Dapagliflozin
■ Causes kidneys to excrete glucose OR
 GLP-1 (-tide)
o Liraglutide, Dulaglutide
■ Stimulates insulin secretion and inhibits glucagon secretion by the
liver (injectable)
 55

Diabetics with concurrent disease:

 SGLT-2 (-flozin)
Type 2 DM with CKD:
 SGLT-2 (-flozin)

Diabetic Medication (Type 2):

Metformin (Biguanides):
 First line for type 2 DM plus lifestyle changes
 Avoid if liver/kidney disease
 Side Effects:
o Gas, bloating, and diarrhea are common with medication
 IV contrast dye testing:
o Hold Metformin on day of procedure and 48 hours after

Glipizide (Sulfonylurea):
 Risk of hypoglycemia so not used often
 Always carry glucose tablets/gel

Actos (Thiazolidinediones):
 Causes fluid retention and may exacerbate heart failure
 Avoid in heart failure (Class II and >)
o Will be on exam

Precose (Alpha glucosidase inhibitors):

 Blocks intestinal absorption of carbs
 Causes hypoglycemia; hold if skipping a meal
 Side Effects:
o Gas, diarrhea, bloating

Prandin (Meglitinides):
 Take with meals due to quick onset
 Can cause hypoglycemia
 Use for post-prandial hyperglycemia

Sitagliptin (DPP-4):
 Decreases appetite
 Adverse effects:
o Nausea, stomach pain, diarrhea, hypoglycemia, pancreatitis
 56

Insulin Types:
Short-acting insulin (Humalog)
 Covers breakfast to lunch/meal to meal
 Duration 3-6 hours

Intermediate-acting insulin (INH)

 Covers breakfast to dinner/evening
 Duration 12-18 hours

Basal insulin (Lantus)

 Covers a 24-hour period

Microvascular damage:
 Retinopathy
 Nephropathy
 Neuropathy
Macrovascular:
 CAD
 PAD
 57

Gastrointestinal:
Acute Abdomen:
Signs and Symptoms:
 Involuntary guarding
 Abdominal wall rigidity
 Rebound tenderness
 Progressive severe abdominal pain
 Bile-stained or feculent (fecal matter/odor) vomitus
o A sign of an obstruction

Ileus:
Symptoms:
 Distended abdomen
 No bowel sounds
 Hyper-tympanic abdomen on percussion due to air trapping
o Normal abdominal sound on percussion is Tympany

Acute Appendicitis:
Symptoms:
 Acute onset of periumbilical pain that is steadily getting worse
 Pain localized at McBurney’s point
o Test Tip (B in McBurney’s for Bellybutton)
 Anorexia
 Low grade fever
 Right lower quadrant (RLQ) pain with rebound tenderness and guarding
 Boardlike abdomen if appendix ruptures
Physical Exam:
 Psoas Sign (iliopsoas/psoas muscle)
o Positive:
■ RLQ abdominal pain on passive right leg hyperextension
 Examiner hyperextends right leg while holding at the hip
 Obturator Sign (obturator muscle)
o Positive:
■ RLQ abdominal pain with internal rotation of RIGHT HIP
 Patient is supine with right leg bent at 90 degrees; rotation
of right hip (full ROM); internal rotation of right hip cause
pain
 Rovsing’s Sign
o Positive:
■ Firm deep palpation of the left lower quadrant (LLQ) of the
abdomen causes severe pain on the RLQ
 Referred pain due to peritonitis (ruptured appendix)
 58

 Markle test (Heel Jar)

o Positive:
■ Pelvic/abdominal pain when patient drops heels onto floor
■ Also positive in pelvic inflammatory disease (PID)
 Rebound tenderness (Blumberg’s sign)
o Palpate abdomen deeply, then release palpating hand quickly
o Positive:
■ Abdominal pain worse when the palpating hand is released
(compared during the deep palpation)
Treatment:
 Refer to ER

Test Tip: Abdominal maneuvers positive with acute appendicitis:

 Psoas/Iliopsoas Sign
 Obturator Sign
 Rovsing’s Sign

Acute Cholecystitis:
Background:
 Higher incidence of cholesterol gallstones (Mexicans, Pima tribe, Native
Americans)
 Ages 40 to 60 most common
 More common in females
 Obesity
 Pregnancy
 Diabetes
 Oral contraceptives (gallbladder disease contraindication for OBC)
Symptoms:
 Severe right upper quadrant (RUQ) or epigastric colicky (comes in waves) pain
typically occurring within 30 min to 1 hour of eating a fatty meal
 Pain may radiate to the right shoulder
 Nausea/Vomiting
 Anorexia
Physical Exam:
 Murphy’s Sign
o Abrupt cessation of inspiration caused by hooking fingers on the right
costal margin and pressing down firmly
Imaging:
 Transabdominal/Liver & gallbladder US
Labs:
 Elevated bilirubin and alkaline phosphatase
Treatment:
 Refer to surgeon
 59

Acute Pancreatitis:
Background:
 Patient may report recent heavy alcohol use
Symptoms:
 Gray Turner:
o Bruising on the flank
■ Mnemonic: (Gray Turner- Turn on your flank)
 Cullen Sign:
o Purple-colored bruises around the umbilicus
 Abdominal pain that radiates to midback “boring” located in the epigastric region
 Fever
 Nausea and Vomiting
 Anorexia
Dx:
 Amylase and Lipase
o Amylase begins to rise 2-12 hours
o Lipase 4-8 hours
o Lipase more specific and sensitive to alcoholic pancreatitis
Treatment:
 Refer to ER

Acute Colonic Diverticulitis:

Symptoms:
 Elderly patient with a sudden onset of mild to moderate abdominal pain and a
mass on the LLQ of the abdomen
 Fever and anorexia
Risk:
 Low fiber diet
 Age 40 and older
 Western society (diet)
Labs:
 Leukocytosis (WBC >11.0)
 Neutrophilia (>70%) and shift to the left band forms
Treatment:
 Refer to ER

Peptic Ulcer Disease (Duodenal Ulcer & Gastric Ulcer):

Duodenal Ulcer (most common ulcer and is benign):
Symptoms:
 Recurrent episodes of gnawing/burning epigastric pain within 2-5 hours
AFTER meals
 PAIN when stomach is EMPTY or hungry
 Feel better after eating, relief with antacids
 Hx of self-treatment with OTC antacids, H2 blockers, or PPI
 60

 90% have H. pylori

Dx:
 Gold Standard: Upper endoscopy with biopsies and H. pylori testing
Treatment:
 Next step is to test for H. Pylori
o Use either a Urea Breath Test (UBT) (specificity 95-100%) or
stool antigen test. These two are the most accurate
o Confirmation of eradication:
■ UBT after 4 weeks post treatment. Stool antigen testing is
less accurate that urea breath test
o Should be off of medication

Gastric Ulcer (higher risk of cancer):

Symptoms:
 Epigastric PAIN that worsens WITH food
 Postprandial belching, early satiety, nausea, sometimes vomiting
 Pain may radiate to the back
 70% of peptic ulcers are asymptomatic
Treatment:
 Upper endoscopy and biopsy with gastroenterology

H. pylori infections (test the following individuals):

 Active PUD
 Past hx of PUD (unless previous cure of H. pylori documented)
 On or will be on chronic NSAID/ASA therapy, others

H. Pylori Treatment (Always do Abx for 14 days):

First Line:
 Bismuth Quadruple Therapy:
o Bismuth (Pepto-Bismol), Metronidazole (Flagyl), Tetracycline QID and
PPI
Triple Therapy:
 Clarithromycin Triple Therapy: (eradication rates <80%; can use if resistance <15%)
o Clarithromycin (Biaxin), Amoxicillin (Amoxil) BID and PPI or
o Clarithromycin BID, Amoxicillin BID and Metronidazole BID and PPI

Zollinger-Ellison Syndrome:
Background:
 Tumor in the pancreas which causes multiple ulcers due to hydrochloric acid
secretion and ulceration
Dx:
 Screening done by serum fasting gastrin level (hold PPI x 7 days)
Treatment:
First line is PPI
 61

The pancreas secretes enzymes:

 Lipase
 Amylase
 Protease
 They help digest protein, fat, and carbs

GERD:
Symptoms:
 Barrett’s Esophagus “pre-cancer-adenocarcinoma”
o Test Tip: refer to GI if patient has had chronic (years) hx of GERD to rule
out Barrett’s esophagus (Dx: via upper GI endoscopy)
 Chronic cough
 Acid sour breath
 Sore throat
 Thinning tooth enamel
 Mid sternal pain (heartburn)
Treatment:
 First line for mild/intermittent:
o Lifestyle and dietary changes and H2 (Zantac or Pepcid) for only 6-8
weeks
 If not effective then PPI (Prilosec, Protonix, Omeprazole, Prevacid) for 6-8 weeks
 If symptoms still present send to GI
Causes:
 BB, CCB, HTN meds increase GERD
Foods to Avoid (relaxes LES):
 Peppermint candy/gum
 Alcohol
 Coffee
 Chocolate
Barrett’s treatment:
 PPI daily and H2 at bedtime. ALWAYS GIVE H2 at BEDTIME

Irritable Bowel Syndrome (IBS):

Background:
 A functional disorder (no changes happen in colon tissue)
 Abdominal cramping from stress
 Does not cause cancer
 Not an inflammatory bowel disease
Symptoms:
 Acute and recurrent abdominal pain with changes in stool and painful defecation
 More common in females
 Either IBS with constipation, IBS with diarrhea, or mixed IBS
 May have mucus, but NO blood or pus
 Increased frequency in defecation
 62

Alarm Signs:
 Age 50 or older, weight loss, abdominal mass, melena/GI bleeding, nocturnal
abdominal pain, iron-deficiency anemia, positive fecal occult blood, family
history of colorectal cancer or inflammatory bowel disease
 Pencil like stool is a sign of colon cancer:
o Most common location is: Sigmoid colon
o Tenesmus incomplete sensation of defecation

Giardiasis:
Background:
 Giardia duodenales is a protozoa that can cause acute diarrhea
 Transmitted by food, water, or fecal-oral route
 Incubation 7-10 days
 Hx of camping or outdoor activity where individuals drank lake or spring water
Symptoms:
 Sudden onset of foul-smelling fatty stools with explosive diarrhea, abdominal
cramping, and flatulence
Labs:
 Stool for C&S and parasites x3
Treatment:
 Tinidazole 2 g single dose or Flagyl 500 mg BID x 5-7 days

Celiac Disease:
Background:
 Allergy to gluten present in wheat, barley, and rye
Symptoms:
 Recurrent hx of abdominal pain, bloating/gas
 Fatigue, migraine headaches, anemia
 Joint pain, weight loss
 In infants/toddlers:
o Growth failure, bloating, nausea/vomiting
Treatment:
 Avoid wheat, barley, and rye

Ulcerative Colitis (UC) and Crohn’s Disease:

Ulcerative Colitis:
Symptoms:
 Colon and rectum only affected
o Rectum always affected
 Rectal bleeding, gross blood in feces more common in UC

Crohn’s Disease:
Symptoms:
 Affected are the ileum, ileocolitis (strictures, fistulas, skip lesions,
cobblestoning)
 63

 Less likely to involve the rectum

 May involve the mouth, small intestine, colon, rectum, and anus
 Distal ileum involved:
 Crampy RLQ abdominal pain
 More common in Ashkenazi Jews
Both:
Symptoms:
 Fatigue, weight loss, prolonged diarrhea with abdominal pain, fever, gross
bleeding
Treatment:
 Refer to GI

Hemorrhoids:
Symptoms:
 Recurrent bright red blood from anal area
 May stain toilet paper and toilet water
 May see blood on the surface of stool
 Look for hx of constipation
 May have a complaint of anal itching or pain during a flare-up
Treatment:
 OTC hemorrhoidal remedies (Preparation H)
 Increase dietary fiber
 Avoid prolonged toilet sitting

Liver Function Test:

Aspartate aminotransferase (AST):
 Elevated after acute MI
 Found in liver, cardiac and skeletal muscle, kidney, and lungs

Alanine aminotransferase (ALT):

 Present in the heart and liver
 More specific for the liver.
o Think of the “L” in the ALT to remind yourself it’s more specific for the liver

Alkaline Phosphatase:
 Bone- growing children and teens, healing fractures, etc.
o Can cause it to be slightly elevated
 Liver, gallbladder, kidneys, placenta, etc.

Gamma-glutamyl transaminase/transpeptidase (GGT):

 Long GGT elevation may be seen in alcoholics
 Helps to determine if high-alkaline phosphatase source is bone or liver
o If GGT is high it’s due to liver cause
o If GGT is not high it’s due to bone cause
 64

Alcoholic Hepatitis:
 If the GGT is elevated and the AST to ALT ratio is at least 2:1 it’s highly suggestive
of alcohol abuse

Gallbladder Disease:
 Elevated bilirubin with/without elevated LFTs with/without elevated alkaline
phosphatase

Acute Hepatitis:
Symptoms:
 Appears 2-6 weeks after exposure
 Fever, fatigue
 Loss of appetite
 Malaise
 Nausea, Vomiting
 Jaundice
 Dark Urine
 Clay-colored stools
 Children usually asymptomatic
Labs:
 ALT and AST (normal 0-40)
o Marked elevation (400-1,000)
 Bilirubin:
o Normal to markedly elevated
Treatment:
 Symptomatic except with hepatitis C which requires treatment

Hep A:
 IgG Anti-HAV (G = GONE)
 IgM Anti-HAV (M = iMmediately infected)

Hep B:
HBsAg = (HAS the word in it)
anti-HBs (immunity)
IgM anti-HBc- (core)
1. If HBsAg is + person is infected
a. What kind of infection
2. Look at anti-HBs
a. + indicates immunity
b. – susceptible to acute infection
3. Look at anti-HBc
a. + infection from virus
b. – immunity from vaccine
 65

Hep C:
 Anti-HCV is screening
o If positive order HCV RNA to confirm test
 Biopsy of liver to check stage
 Chronic Hep C: just has elevations in ALT
o “Remember the “L” in ALT indicated it’s more specific for the liver
 66

Genitourinary:
Serum Creatinine:
Definition:
 An end product of creatine which comes from muscle metabolism
 Creatinine is used to figure out the estimated GFR (eGRF)
o Creatinine clearance usually reflects the GFR
o When kidney function declines, creatinine usually increases
Value:
 >1.3 mg/dL abnormal
 Males:
o 0.7-1.3 mg/dL
 Females:
o 0.6-1.2 mg/dL
Increased:
 Gender (slightly higher in males), muscle mass, older age, race (AA), CKD, high
protein diet, acute kidney injury, renal disease, nephrotoxic drugs
Decreased:
 Low muscle mass, malnutrition, pregnancy, female sex

Estimated GFR (eGFR):

 Normal: >90 mL/min
 Not a direct measurement; derived using the serum creatinine and other variables
to figure out the eGFR

BUN (blood urea nitrogen):

Definition:
 Urea comes from protein metabolism
 A waste product that’s excreted by the kidneys
 Serum BUN and/or creatinine increase when renal function is impaired

Acute Kidney Injury (acute renal failure):

Background:
 Abrupt decrease in kidney function with an onset from a few hours to a few days
 GFR <60 mL/min with an elevated serum creatinine >1.3 mg/dL and a reduced
urine output
 May require dialysis
 Most common cause is related to drugs (medications)
Pre-renal causes:
 Hypotension, volume depletion (diarrhea, vomiting, bleeding, shock), HF, drugs
Intrinsic renal causes (kidney damage):
 Interstitial nephritis (adverse reaction to drugs), kidney disease
(glomerulonephritis)
 67

Post-renal causes (blockage):

 BPH, kidney stones, cancer of the bladder or prostate, blood clots in the urinary
tract
Symptoms:
 Edema of face and lower extremities
 Lungs with crackles if volume overload
 Elevated BP
 Nausea/Vomiting
 Confusion, fatigue

Asymptomatic Bacteriuria:
Definition:
 Presence of one or more species of bacteria growing in the urine (105 CFU/mL) in
the absence of UTI symptoms
Screening and Treatment:
 Screen and treat pregnant women. Pregnant women are at higher risk for
pyelonephritis (Nitrofurantoin and beta-lactams (ampicillin, cephalexin) are
preferred

Urine Culture Definition:

 UTI (treat)
o >100,000 (105) colony forming units (CFU’s) of a single organism
 No infection
o <10,000 CFU
 Contamination
o >100,000 CFU’s mixed bacteria

Urinary Tract Infections (UTI) Females:

Bacteria:
 Gram negative Enterobacteriaceae such as E. Coli, Klebsiella, and/or staph
saprophyticus
Risk Factors:
 Female, pregnancy, sexual intercourse, Hx of UTI or recent infection
 Diabetes, immunocompromised
 Spermicide (nonoxynol 9) use alone or with diaphragm
Symptoms:
 Dysuria, frequency, urgency, nocturia, some have suprapubic discomfort
Labs:
 UA: leukocytes, positive/negative nitrites
 Urine for C&S: >105 CFUs of a single organism (E. coli)
Treatment:
 First Line:
o Trimethoprim-sulfamethoxazole (Bactrim) BID x 3 days (if <20%
resistance to Bactrim or Sulfa allergy)
 68

o Nitrofurantoin 100 mg BID x 5 days (avoid in last trimester of pregnancy

due to hemolytic anemia)
 Alternatives:
o Fosfomycin 3 g x one dose
o Augmentin BID x 5-7 days
o Ciprofloxacin 250 mg BID or levofloxacin 250 mg QD x 3 days
 Adjunct treatment:
o Pyridium 200 mg TID x 2 days PRN for dysuria
■ Inform patient that it will turn urine orange
■ Contraindicated in pregnancy

Urinary Tract Infections (UTI) Males:

Background:
 Recurrent UTI’s in males are classified as complicated because it may be caused
by epididymitis, prostatitis, orchitis, urethritis, pyelonephritis, anatomic
abnormalities, or kidneys stones
 If sexually active use NAAT to test urine for gonorrhea/chlamydia
 During infancy UTI’s are more common in males
o Have asked on exams before
Bacteria:
 E.
coli
Symptoms:
 Dysuria
 Frequency
 Urgency
 Nocturia
 May or may not have suprapubic pain
o If the prostate is involved there will be a lot of suprapubic pain
Treatment (minimum 7 days duration):
 First Line:
o Bactrim DS BID (if local resistance <20%)
o Ciprofloxacin 500 mg BID
o Nitrofurantoin 100 mg BID

Acute Uncomplicated Pyelonephritis:

Bacteria:
 Gram negative Enterobacteriaceae (E. coli, Klebsiella, Proteus)
Symptoms:
 Acute onset of fever with/without chills/rigors
 Flank pain
 Nausea/Vomiting
 Dysuria, frequency, urgency, nocturia
o Some males may have signs of prostatitis (perineal pain)
 Elderly may not have a fever, may have changes in LOC (delirium, confusion),
falls
 69

Treatment:
 Only mild uncomplicated cases treated as outpatient
 First Line:
o Fluoroquinolones (Ciprofloxacin 500 mg BID or levofloxacin QD) x 5-7
days

Diagnosis of a kidney stone:

 Ultrasound

Elderly female with new onset of incontinence:

 Order a UA and Culture

RBC found in urine:

 Glomerulonephritis

3+ protein in urine:
 Do a 24-hour urine for protein and creatinine clearance
 70

Neurological:
Subarachnoid Hemorrhage:
Symptoms:
 “Worst headache of my life”
 Thunderclap headache
 Vomiting, seizures, confusion, coma, stiff neck
 May experience sentinel headache few weeks prior

Subdural Hematoma:
 Usually due to trauma, elderly with hx of falling, on anticoagulants/ASA
 Skateboarding concussion
 Diagnosed with CT (Never do Contrast if you suspect a head bleed)

Post-Concussion Syndrome (PCS):

 Sequelae after traumatic brain injury
 Most recover in 1-2 weeks but some have symptoms for several months
Symptoms:
 Headache onset within 7 days post injury
 Neck pain
 Dizziness, Nausea/Vomiting, noise sensitivity, memory problems, fatigue,
insomnia

Aphasia:
Broca’s Aphasia (expressive aphasia):
 Broken speech
 Difficulty forming words but understands language
 Needs speech therapy
 Location:
o Frontal lobe
Wernicke Aphasia (receptive aphasia):
 Able to speak however, sentences are garbled
 Fail to realize that they are saying wrong words
 Location:
o Frontal lobe

Migraine:
Symptoms:
 Throbbing pain located behind one eye with nausea/vomiting
 Photophobia and phonophobia
 Some have prodrome (aura) scotomas (blind spots), flashing lights
 Condition greater in women than men
Triggers:
 Red wine, fermented foods, MSG, and stress
 71

Treatment:
 Abortive:
o Triptans, analgesics/caffeine, NSAIDs
 Prophylaxis:
o Used if migraines more than 3 per month
o TCA (Amitriptyline), beta-blockers (Propranolol), CCB, Anticonvulsants
(gabapentin, topiramate)
 If not treated can become bilateral and last >24 hours

Cluster Headache:
Symptoms:
 One sided lancinating/excruciating pain behind one eye/temple with ipsilateral
lacrimation
 Nasal congestions, and Horner syndrome (one-sided ptosis, miosis)
 Ice pick headache
 Condition greater in men than women
 Higher risk for suicide and it occurs several times/day for weeks to months
Treatment:
 Abortive:
o 100% oxygen by mask at 12 L
o Sumatriptan by injection
 Prophylaxis:
o Verapamil (CCB)

Tension-type Headache:
Cause:
 Medication overuse
Symptoms:
 Bilateral sensation of “tightness” or “band like” pressure
 Mild to moderate pain
 Muscle tenderness on the head, neck, or shoulders
Treatment:
 Acute Treatment:
o Acetaminophen
o Aspirin
o NSAIDs
 Prophylaxis:
o Amitriptyline or other TCA’s
o Venlafaxine XR

Trigeminal Neuralgia (aka Tic Douloureux):

Affects:
 Located on branch CN 5
Symptoms:
 One-sided excruciating “electric” like pain on the cheek or peri-nasal area
 72

 Aggravated by chewing, talking, cold air

Treatment:
 Carbamazepine (Tegretol)

Pseudotumor Cerebrii:
Symptoms:
 Obese female with headache, papilledema, high ICP, diplopia, transient visual
symptoms, tinnitus
Treatment:
 Carbonic anhydrase inhibitors (acetazolamide)

Temporal arteritis/Giant cell arteritis:

Symptoms:
 One temple indurated like cord
 Abrupt visual changes
 Blindness
 Amaurosis fugax (transient monocular loss of vision or partial visual field defect)
 Most have Polymyalgia Rheumatica (30%)
Labs:
 Elevated sed rate and CRP
Treatment:
 High dose steroids
o Prednisone 60-100 mg/day for 2-4 weeks with a taper
 Refer to ER

Polymyalgia Rheumatica:
Symptoms:
 Bilateral joint stiffness, aching of the shoulders, neck, hips, and torso.
 Problems with dressing due to severe morning stiffness (>30 minutes)
 Usually affects people 50 and older. Most commonly females
 May have systemic symptoms (fatigue, low grade fever, etc.)
 High risk for temporal arteritis
Physical Exam:
 Decreased ROM of the shoulders, neck, and hips
Labs
 Elevated sed rate and CRP
 Normocytic anemia
Treatment:
 Prednisone long term 10 to 20 mg/day
Side Effects of long-term steroids:
 Infections, osteoporosis, weight gain, depression, cataracts, glaucoma, HPA-axis
suppression, fluid retention
 73

Bell’s Palsy (CN7):

Symptoms:
 One sided facial paralysis due to inflammation/swelling which results in
compression of CN 7 (facial nerve)
 Only motor function affected; sensation is intact
o Most cases resolve spontaneously from 3 weeks to 3 months
 Unable to raise eyebrow, shut eyes completely, grimace, and grin
Rule out:
 Lyme disease, shingles, TIA, MS
Treatment:
 Artificial tears
 Patch ipsilateral eye at night (avoids drying cornea)
 Prednisone x 10 days (with taper)
 Antiviral (Acyclovir 5x/day for 10 days

Seizures:
Absence seizure (petit mal):
 Sudden brief lapse of inattention

Tonic-clonic seizure (grand mal):

 Tonic phase happens first:
o All muscles stiffen, pt. loses consciousness and falls
 Clonic phase happens next:
o Arms and legs jerk rapidly

Fever decreases seizure threshold

Multiple Sclerosis (MS):

Symptoms:
 Optic neuritis (pain & temporary vision loss)
 Lhermitte sign (electric shock sensation that radiates from back of neck down the
spine)
 Fatigue
 Sensation of pins & needles
 Heat sensitivity
Dx:
 MRI
Treatment:
 Refer to neurologist
 74

Transient Ischemic Attach (TIA), Stroke, Cerebrovascular Accident (CVA):

Background:
 Either embolic or hemorrhagic
o Most strokes embolic
 If hemorrhagic stroke pt. often has poorly controlled blood pressure
Symptoms:
 Abrupt onset of a severe headache
 Nausea/Vomiting
 Nuchal rigidity (subarachnoid bleed)
 Acute onset of stuttering/speech disturbance
 One sided facial weakness, and weakness of the arms and/or legs (hemiparesis)
TIA:
 Is a transient episode of neurologic dysfunction caused by focal ischemia without
acute infarction of the brain as seen in stroke

“FAST” Mnemonic for Stroke:

 F- Face drooping (have the patient smile. Is the face lopsided?)
 A- Arm weakness (have the patient raise both arms. Does one arm drift down?)
 S- Speech difficulty (have the patient say “The sky is blue”
 T- Time to call 911 (Don’t delay calling 911 even if symptoms resolve)

Cranial Nerves:
 CN V (Trigeminal):
o Herpes keratitis and corneal abrasion
 EOM:
o CN III (Oculomotor), IV (Trochlear), VI (Abducens)
■ Common on the exam
 IV:
o Superior oblique muscles
 VI:
o Lateral muscles
 CN I (Olfactory):
o Nose
 CN XI (Spinal accessory):
o Shoulder shrug/ ROMBERG test
 CN VIII (Acoustic):
o Ears
 CN VII (Facial):
o Bell’s Palsy
 75

Fibromyalgia:
 Tender points in at least 11/18 body points
 Widespread pain for at least 3 months above and below waist
 All other possible causes ruled out

Carpal Tunnel Syndrome:

 MEDIAN NERVE
 Tinel’s sign t=tapping
 Phalen’s sign- putting fingers together
 76

Hematology:
Memorize these lab values for ANCC; numbers will be given to you on AANP:

Complete Blood Count (Adults):

1. Hemoglobin
 Males <13 g/dL
 Females <12 g/dL

2. Hematocrit (can multiply hemoglobin by 3 to obtain hematocrit estimate)

 Males <40%
 Females <36%

3. MCV (mean corpuscular volume-size of the RBC)

 80-100 fL

4. MCHC (mean corpuscular hemoglobin concentration)

 Measures the color of RBC

5. Serum Ferritin
 Most sensitive test to detect iron deficiency anemia.
 <15 ng/mL diagnostic for iron deficiency anemia
 Normal in alpha/beta thalassemia trait

6. Serum Iron
 Decreases with IDA
o Not as sensitive as Ferritin

7. TIBC (total iron binding capacity) & transferrin

 Transferrin is the protein that transports iron
 Elevated in iron deficiency anemia

8. Reticulocyte count (0.5% to 1.5% of RBC mass)

 Immature red blood cells
 Elevate in a few days to a week after supplementing with iron/folate/or B12 if it was
deficient

9. RDW (red cell distribution width)

 Measures the difference in RBC size (anisocytosis)
 Elevated RDW in anemia caused by vitamin or mineral deficiencies (iron, B12, folate) or
with thalassemia’s
 77

Differential Diagnosis: Depends on RBC size

MCV <80 (microcytic)
Iron-deficiency anemia
Thalassemia trait (alpha or beta)

MCV 80-100 (normocytic)

Anemia of chronic disease (chronic inflammation-autoimmune disease)
Anemia of CKD (deficiency in erythropoietin production)

MCV>100 (macrocytic/megaloblastic)
B12 deficiency anemia
Folate deficiency anemia

Microcytic Anemias:
Iron Deficiency:
Screening test:
 CBC (for all anemias)
Symptoms:
 Fatigue, weakness, pallor, angular stomatitis/cheilitis
 Glossitis
 Spoon-shaped nails (koilonychia)
 PICA and pagophagia (craving ice)
 Cramping of the calves when climbing stairs
Causes:
 Slow chronic blood loss (heavy menses, ulcers, colonic polyps, colon
cancer), increased physiologic requirement (infants, teens, pregnancy),
inflammatory bowel disease, CHF, bariatric surgery, etc.
Labs:
 Gold Standard: Serum Ferritin
 MCV <80
 Microcytic hypochromic
 TIBC is increased
 Ferritin/iron are Decreased
Treatment:
 Ferrous sulfate 325 mg po TID (take with vitamin C to help with better
absorption)
o Side Effects: Constipation and black colored stools
 Check reticulocyte 1 week after starting iron to make sure you don’t have
bone marrow suppression
 Must do treatment for 3-6 months

Thalassemia Trait (alpha or beta):

Background:
 Genetic defect (autosomal recessive)
 78

 Affects Mediterranean (Italian, Greek, Arabs, etc.) or Southeast Asian

(Chinese, Filipinos)
Labs:
 MCV <80
 Microcytic Hypochromic
 Gold Standard: Hemoglobin Electrophoresis
o This is the standard in sickle cell as well
 Only beta thalassemia will be abnormal NOT alpha (Alpha-Asians,
BETA- by sea)
 Check Ferritin this will be either normal or slightly elevated
Treatment:
 None
 Refer to genetic counseling 1:4 chance child with active disease

Normocytic Anemias:
Anemia of Chronic Disease:
Screening test:
 CBC
Symptoms:
 Older patient with an autoimmune condition (RA, lupus, etc.) or with
chronic illness. Will have typical anemia signs/symptoms (fatigue, pallor,
etc.) or CKD (low EPO production)
Diagnostic test:
 None except that the MCV will be between 80-100 fL
Treatment:
 Correct the cause if possible

Normocytic Anemia Labs:

MCV between 80-100 (normocytic)
MCHC: normal color (normochromic)
Etiology: chronic inflammation interferes with iron uptake

Macrocytic Anemias:
Differential Dx:
 B12 deficiency or Folate deficiency
Screening test:
 CBC (MCV>100 fL)
Next step:
 Order serum B12 AND Folate levels
Symptoms:
 Elderly patient (60 or older)
 Muscle weakness, paresthesia (tingling/numbness) of hands and feet
 Reports leg stiffness and falls, trouble walking “clumsy” dropping objects
 Glossitis (bright red, smooth, tender tongue)
 79

 If severe: optic neuritis, depression, impaired memory, dementia

 B12 or pernicious will be the ONLY one with neuro findings
 Pernicious (autoimmune destruction of parietal cells in fundus) think
people that get their stomach taken out (gastric bypass) with pernicious
must do B12 injections lifelong
 With B12 only temporary
Labs:
 MCV>100
 Macrocytic normochromic
 MMA level increases
Causes:
 Gastrectomy/obesity surgery, vegans, infants of vegans, hx autoimmune
disease, Crohn’s disease, HIV
 Pernicious anemia (B12 deficiency) results in a macrocytic and
normocytic anemia with neurologic symptoms which can be permanent if
not treated
Treatment:
 B12 IV/IM weekly until deficiency is corrected, then once/month. Needs
lifelong treatment
 Impaired absorption of B12:
o High doses of oral B12 1000-2000 mcg daily
 B12 foods:
o All meat products of animal origin (Think of a BIG BEEFY
TONGUE)

Folate Deficiency Anemia:

Cause:
 Most common cause is inadequate intake (undernutrition, alcoholics),
increased demand (pregnant, lactation), impaired absorption (celiac
disease, drugs)
Symptoms:
 Alcoholic or elderly patient with pallor, fatigue, glossitis, prolonged
diarrhea, dyspnea
 NO neuro signs or symptoms
Labs:
 MCV >100
 Macrocytic normochromic
Treatment:
 Folic acid 1-5 mg/day
 Pregnant women need 400 mcg 1 month prior to pregnancy
o (Higher risk for neural tube defects)
 Eat green vegetables
 80

Sickle cell:
Screening:
 CBC
Labs:
 Gold Standard: HGB electrophoresis
Dx:
 Could do a CVS (Chorionic Villus Sampling) or Amniocentesis to check at 8-10
weeks pregnancy for sickle cell
 Give sickle cell patients their vaccines to protect from illnesses such as
pneumonia/flu

Thrombocytopenia:
Definition:
 Platelet count <150,000 (150,000-450,000)
Cause:
 Most common cause: idiopathic thrombocytopenic purpura (ITP)
Symptoms:
 Epistaxis
 Petechiae to purpura
 Easy bruising (ecchymosis), severe bleeding with mild trauma
 Hematuria
 81

Musculoskeletal:
Navicular Fracture (scaphoid bone):
Symptoms:
 Falling on an outstretched hand (“FOOSH”) or falling forward with
hyperextension of the wrist
 Pain below thumb area (anatomic snuffbox)
Dx:
 X-ray won’t show fracture for 2 weeks
 MRI most sensitive <24 hours
 Bone scan to diagnose at 72 hours
Treatment:
 Thumb spica cast and send to ortho

Colles Fracture (aka “Dinner Fork” fracture):

 Distal radius fracture with radius tilting upward
 Radius is the most commonly fractured wrist bone
Treatment:
 Refer to ER

Low back pain:

 Usually due to soft-tissue inflammation, sciatica, sprain, muscle spasms, or
herniated disc (L5-S1)
o Most cases resolve within 4 to 6 weeks
 Sciatica is a form of radiculopathy and one of the most common causes is a
herniated disc
 Both aggravated by long periods of sitting and feel better with WALKING
 Lumbar stenosis is aggravated by long periods of standing and walking. Releived
by sitting and rest
Dx:
 MRI to rule out a herniated disk

Sciatica:
Symptoms:
 Impingement of L4-L5 nerve root that results in sharp burning pain in the midline
through the buttock and may radiate to the posterior thigh to the top of the foot
 May have weakness of affected leg and foot
Dx:
 Straight Leg Raise (SLR)
o SLR positive with pain
■ Raise one leg up straight until pt. reports pain (buttock, thigh, or
calf)
 82

Cauda Equina Syndrome (horse tail):

Symptoms:
■ Progressive loss of bladder sometimes bowel function
■ Progressive numbness of the pelvic area in a saddle pattern (saddle anesthesia)
■ Bilateral sciatica and progressive weakness of legs
Treatment:
Refer to ER

Ankylosing Spondylitis (“bamboo spine”):

Background:
 Progressive seronegative arthritis (HLA-B27 positive)
 Chronic inflammation of the spine
 Affects men more than women
 Onset between puberty to age 40
Symptoms:
 Progressive low back pain associated with a lot of stiffness and pain that starts at
the cervical spine THEN thoracic THEN lumbosacral
 Severe stiffness of the spine which is painful
 Generalized symptoms (low-grade fever, fatigue, etc.)
Physical Exam:
 Loss of lateral flexion (early finding)
Workup:
 CRP and ESR are elevated
 MRI and X-ray for imaging
Treatment:
 NSAIDs:
o Indomethacin 25-50 mg BID-TID

Orthopedic Injuries:
 R.I.C.E
o R-Rest
o I-Ice (ice on x15 minutes then take off for 20). Use for the first 24-48
hours
■ Do not apply directly to skin, use cloth between ice pack and skin
o C-Compression to decrease swelling (wrists, ankles, knees)
o E-Elevation (at level or above level of heart)
 Medication:
o Acetaminophen 325-650 mg every 4-6 hours PRN
o Ibuprofen 400-600 mg every 4-6 hours PRN
o Naproxen 250-500 mg every 12 hours PRN
 Isometric exercises:
o Spare the joints, helps build muscles (resistance bands)
 Aerobic exercises:
o Swimming, walking, bicycling
 Flexibility:
 83

o Stretching, ROM of shoulders, calf stretch

McMurray Test:
 Assesses medial meniscus injury
 Listen for a “Click” either heard or palpated are positive findings
o If a click is heard or palpated the next step is to order an MRI
Imaging:
 Gold standard: MRI

Drawer Test:
 Looks for knee/ankle instability
Anterior Drawer:
 Checks for anterior cruciate ligament (ACL) laxity
Posterior Drawer:
 Checks for posterior cruciate ligament (PCL) laxity

Lachman Test:
 Very sensitive for ACL “LAXITY”
o More sensitive for ACL than drawer test

Valgus Stress Test:

 Medial Collateral Ligament:
o Positive: laxity or torn medial collateral ligament of the knee
■ Think of gum sticking (Valgus). It brings knees together i.e.,
medial meniscus test
Varus Stress Test:
 Lateral Collateral Ligament:
o Positive: laxity or torn lateral collateral ligament of the knee
■ Thing of Varus as air towards the outside

Rotator Cuff Tendinitis:

Symptoms:
 Gradual or acute onset of pain with overhead movements of the arm
 Lifting/reaching may cause pain
 Disturbed sleep with sharp pain
 Arm weakness, dull ache
 Apprehension test rules it in or out
o Positive- pain or weakness when resistance is applied
Treatment:
 NSAIDs, PT, avoid excessive overhead activity during acute phase, RICE (Rest,
Ice, Compression, Elevation)
 84

Lateral Epicondylitis:
 (TENNIS) pain in outside elbow
 Worse with twisting or grasping
 Forearm muscles (flexors/extensors)
Treatment:
 Follow RICE. NSAIDs PRN
 Tennis elbow strap (epicondylitis strap) PRN

Medial Epicondylitis:
 (GOLFER) inner elbow pain by funny bone
 Baseball, bowlers
 Tenderness to palpation over the inner aspect of the elbow (medial epicondyle)
Complications:
 Ulnar nerve neuropathy/palsy

Distal Bicep Tendon Rupture:

Symptoms:
 Sudden pain with a popping noise at distal bicep that is followed by bruising on
the bicep area
 Difficulty twisting the forearm or bending the elbow
 Bicep will roll into a giant ball
Dx:
 Gold Standard: MRI
 History and clinical exam
 Hook test
Treatment:
 Surgery

DeQuervain’s Tenosynovitis/Tendonitis
Symptoms:
■ Benign disease from overuse and heavy lifting
■ Inflammation of the tendon sheath causing entrapment of the thumb tendons
and wrist pain with grasping
Test:
 Finkelstein test:
o Positive if there is pain and tenderness on the wrist at the radius
Treatment:
■ Wrist splint 24 hours a day x 3-6 weeks
■ NSAIDs for pain
■ Ice packs

Morton’s Neuroma:
Background:
 Scarring of the common digital nerve due to chronic pressure from wearing high-
heels and tight-fitting shoes, obesity, flat feet, etc.
 85

Symptoms:
 Pebble-like mass and pain in the space between the 2nd and 3rd toes (metatarsals)
 Burning and numbness
Dx:
 Mulder’s Sign:
o Use one had to grasp 1st and 5th metatarsal heads together while applying
pressure on the forefoot
■ Positive:
 Reproduce the pain and may hear a click; pain relived when
compression stops
Treatment:
 NSAIDs, avoid wearing high heels, avoid going barefoot and wearing tight-fitting
shoes
 Send to podiatry for steroid injection of nerve/ganglion

Plantar Fasciitis (“stone bruise”):

Background:
 Inflammation of the plantar (foot) fascia due to overuse
Symptoms:
 Severe pain on the heel of the foot upon getting up from bed in the morning
 Pain may get a little better throughout the day
Treatment:
 Stretching exercises for the foot (stretch Achilles tendon and plantar fascia)
 Apply ice to sore area 3-4 times/day
 NSAIDs
 Do not walk barefoot
 Wear sneakers and other shoes with good padding

Osteoarthritis (OA)/Degenerative Joint Disease (DJD):

Background:
 Most common joint disease worldwide
 Affects weight bearing joints (knees, hips) and hands
 Can have unilateral or bilateral joint involvement
Symptoms:
 Large weight bearing joints and hands
 Early morning stiffness with inactivity (last less than 30 minutes)
 Pain aggravated by cold weather, changes in weather, prolonged or overuse of
affected joint
 Heberden’s nodes (DIP) only in OA (DJD)
o Test Tip: Heberden is HIGH above; Bouchard is below
■ Also, HeberDIP nodes to remind you they are in the distal
interphalangeal joints
Treatment:
 FIRST LINE: Acetaminophen
 86

 EXERCISE: Isometric exercises for knee OA

o Non-weight bearing, like biking, swimming, stationary bike
 If inflammation present: NSAIDs PRN (Ibuprofen, naproxen)

Rheumatoid Arthritis (RA):

Background:
 Systemic autoimmune disease that affects women more than men
 Symmetrical/bilateral inflammatory arthritis that involves multiple joints
 Destroys joints and leads to loss of physical function and quality of life
Symptoms:
 Early morning stiffness that is longer than OA (1 hours +)
 Pain, warm, tender, swollen joints that are not relived by rest like OA
 Symmetrical involvement
 Joint space narrowing
 Bouchard’s nodes (OA and RA in PIP joints)
o Swan-neck deformity, Boutonniere deformity, Rheumatoid nodules is
the description on the exam
 May have normocytic anemia
Treatment:
 Refer to rheumatologist
 NSAIDS, steroids, DMARDS, TNF
Complications:
 Uveitis
o Refer to ophthalmologist

Bouchard’s nodes:
 Present in both RA and OA on PIP joints

Risk factors for postmenopausal osteoporosis:

 Older women
 White/Asian descent
 Thin; small body frame
 Chronic steroids; androgen deficiency; hypogonadism; anorexia; bulimia; gastric
bypass; celiac disease; hyperthyroidism; ankylosing spondylitis; RA; low calcium
intake; vitamin D deficiency; inadequate physical activity; alcohol/caffeine
intake; smoking

How to prevent fractures in patients with a low vitamin D, high TSH, and a low HCT:
 Take 600-800 Vitamin D
 Take 1000-1200 of Calcium
 87

Gout:
Symptoms:
 Severely painful podagral and/or several joints (ankle, knee, wrist, etc.)
 May have had recent alcohol intake and/or seafood/steak meal
 Warm to the touch, red, and swollen metatarsophalangeal (MTP) joint
Dx:
 Elevated uric acid level (>7 mg/dL) and clinical findings
 Tophi:
o Small white nodules filled with urates (ears and joints)
 Rule out septic joint
Treatment:
 Acute phase:
o Provide pain relief. If on allopurinol continue same dose; do not stop
medication and do not increase
o Oral glucocorticoid (prednisone), NSAIDs, or colchicine
 First Line:
o NSAIDs (naproxen, indomethacin)
 If that is not an option:
o Colchicine 0.6 three times/day or 1.2 mg (2 tabs first) followed by 0.6 (1
tab) one hour later

Medial Tibial Stress Syndrome and Medial Tibial Stress Fracture:

Symptoms:
 OVERUSE, more common in runners
 Results in inflammation of the muscles, tendons, and bone on the tibia “inner
border” painful on palpation
 Pain may be sharp/stabbing or dull/throbbing
Dx:
 DO bone scan or MRI. A plain X-ray won’t show a stress fracture
Treatment:
 RICE
 88

Mental Health:
If the elderly can’t sleep, have insomnia, etc. make sure to screen for depression

Alcoholism:
CAGE
o 4 questions to screen for alcohol abuse
o A score >2 suggests alcoholism
 C-Cut down
 A-Annoyed
 G-Guilty
 E-Eye opener
 Question may ask who is least likely or more likely to abuse alcohol
o 12 step program alcoholics anonymous
o Al-anon is for families
o Al-teen for teenagers

Evaluate for withdrawal:

 Tremors, anxiety, tachycardia, increased BP, insomnia, delirium tremens (DT)
(confusion, hallucinations, delusions, seizures)
Labs:
 Elevated GGT (alone or with elevated ALT/AST)
o Elevated due to liver cause
 MCV>100 (macrocytosis)
o Due to deficiency in folate
 Hypertriglyceridemia
 Thrombocytopenia
Treatment:
 Refer to ER
 For DT: benzodiazepines (Librium, valium), clonidine, etc.

Anorexia:
Symptoms:
 Lanugo
 Osteoporosis
 BMI <18.5
 Peripheral edema
 Heart problems (cardiomyopathy or arrhythmias)
 Evaluate for medical complications, exclude medical disease (DM, hyperthyroid,
celiac, etc.)
 Most common cause of death: cardiac
 89

Attention Deficit Hyperactive Disorder (ADHD):

Symptoms:
 Hyperactivity, impulsivity, and/or inattention that affects function (school,
emotions, socialization)
 Behavior therapy, limit setting, etc.
 In kids will be present prior to 12 years
 Symptoms last >6 months, should be evident in at least 2 different settings
Treatment:
 Behavioral therapy first, then meds unless school age child
o Adderall, Ritalin, Vyvanse, Strattera

Major Depression:
 Screening tool PHQ-9
Symptoms:
 Present for at least 2 weeks:
o Sad mood, diminished interest/pleasure in things that used to give pleasure
(anhedonia) PLUS the presence of at least 5 of the following
■ Energy: fatigued or irritable
■ Poor self-image: feelings of guilt/hopelessness
■ Cognition: difficulty concentrating, thinking, indecisive
■ Sleep: insomnia or hypersomnia
■ Appetite: anorexia or increased appetite
■ Weight loss (not intentional form dieting) or weight gain
■ Diminished interest or pleasure in most activities
Minor Depression:
Symptoms:
 Presence of 2-4 symptoms of depression listed above (including depressed mood
or loss of pleasure/anhedonia)
Newly diagnosed for both:
 Rule out other causes like hypothyroidism, autoimmune disorders, severe anemia,
etc.
Labs for both:
 CBC, BMP, TSH, UA
Treatment:
 First Line:
o SSRIs. Can take up to 6 weeks for full effect. Patients under 25 watch for
suicide risk
o Make sure patient is not suicidal or homicidal before sending them home
■ Fluoxetine (Prozac) has the longest half-life of SSRIs
■ Paroxetine (Paxil) shortest half-life (wean off slowly). Paxil has
the highest risk of causing erectile dysfunction

Elderly and Depression:

 SSRIs have the best safety profile
 Citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft)
o Lowest potential for drug-drug interaction based on cytochrome P-450
 90

■ Citalopram and escitalopram preferred

Acute Serotonin Syndrome:
Symptoms:
 Dilated pupils
 High fever
 Muscular rigidity
 Mental status changes
 Hyperreflexia
 Clonus
 Uncontrolled shivering
Causes:
 High levels of SSRIs, MAOIs, TCAs, or introduction of a new drug. Could be
potentially life threatening
Treatment:
 Benzodiazepines, Periactin, IV fluids, stop offending drug (s)

Insomnia:
Primary Insomnia:
 Not caused by medication or disease and is either acute or chronic
Cause:
 Stress, shift work, travel to another time zone
Secondary Insomnia:
 A side effect of medication or disease (depression, chronic pain, GERD,
dementia, delirium, stimulants)
Sleep-onset:
 Difficulty initiating sleep (but when asleep can sleep throughout the night)
Early-awakening:
 Wakes after one hour or a few hours after falling asleep
Management:
 First Line:
o Sleep hygiene, sleep diary
o Kava Kava:
■ Use for anxiety and insomnia, don’t mix with other sedating
medications such as benzos
o Melatonin
o Valerian
o Diphenhydramine
o Use non-benzodiazepines like Lunesta and Ambien for elderly to help
with insomnia

Bipolar:
Symptoms:
 Mood swings between mania (needs less sleep, talkative, grandiose, easily
distracted) with depression (bipolar depression)
 Higher risk of suicide, substance abuse, anxiety disorders
 91

Type I:
 Full blown manic episodes (grandiosity, less sleep, talkative, impulsive, etc.)
Type II:
 Hypomania (milder symptoms that type 1)
Labs:
 TSH (Lithium can destroy thyroid causing hypothyroidism)
Treatment:
 Lithium salts (affect TSH, Kidney), anticonvulsants (Depakote), Antipsychotics

Atypical Antipsychotics:
 Zyprexa, Seroquel, Risperdal
Side Effects:
 OBESITY, DM2, check BMI Q3 months. CAUSES WEIGHT GAIN

Seasonal Affective Disorder:

Symptoms:
 Depression occurring during winter months
 Causative factors include circadian rhythm
 Drop in serotonin
 Change in melatonin level
Treatment:
 Light therapy, antidepressants, psychotherapy/talk therapy

Anxiety Attack:
 Treat with a Benzodiazepine for a SHORT PERIOD OF TIME

Generalized Anxiety Disorder:

 SSRI, SNRI, Wellbutrin. May do benzo for short time

Abuse: Common Factors

Symptoms:
 Delay in seeking treatment. Pattern of injuries inconsistent with history
 Injuries on the trunk vs. extremities
 Pregnant women- increased risk
 New onset of STI (consider especially in the elderly) or anyone not sexually
active
Interview:
 Take a history in a private room and separate victim from potential abuser
PE:
 Spiral fractures (greenstick fx.), multiple healing fractures especially in the rib
area, burn marks with pattern
 92

SSRI are ALWAYS first choice FOR MAJOR and MINOR DEPRESSION as well as PTSD.
Causes low sperm count

Wellbutrin can help with sexual dysfunction from SSRI/Paxil. Do not give it to people with
seizures or anorexia

TCA: easy to overdose on don’t give to patients with suicidal thoughts/ideation

If a patient has been on a benzo for long term make sure to wean it. Abrupt withdrawal can cause
seizures
 93

Men’s Health Review:

Normal Prostate:
 Firm/smooth, slightly movable, and nontender
 Prostate gland is under the bladder

Benign Prostatic Hyperplasia (BPH):

Symptoms:
 Older male with hx of gradual onset of obstructive voiding such as weak stream,
dribbling, incomplete emptying, frequency, urgency, nocturia
Digital Rectal Exam (DRE):
 Palpating the posterior surface on the anterior wall
 Symmetrically rubbery/boggy (spongy), firm, enlarged, and nontender
Plan:
 PSA (mildly elevated in BPH) and transrectal US
o Normal PSA <4.0 ng/mL
o Do labs before DRE as exam will increase PSA in blood
Treatment:
 First Line:
o Alpha-Blockers (Tamsulosin (Flomax) QD
 Hytrin and Cardura are good for a patient with HTN and BPH
o Take at night due to potential adverse reactions of hypotension, syncope,
dizziness, blurred vision
 If on Finasteride (Proscar) 5-alpha-reducatse inhibitor must multiply the PSA x2
o Finasteride can reduce prostate by 50%; takes 6 months for prostate to
shrink
Complications:
 Bladder outlet obstruction, UTIs, kidney failure

Prostate Cancer:
 Most common cancer in males
Symptoms:
 Stony, hard, nodular, and painless when doing a DRE
 Obstructive voiding symptoms (dribbling, weak stream, nocturia)

 PSA: ≥4.0 ng/mL

Labs:

Risk Factors:
 Older age (>50 years)
 Black/African ethnicity, positive family history (father, brother)
 Obesity
Treatment:
 Refer to urologist
 94

Acute Bacterial Prostatitis:

Bacteria:
 Most common (E. coli) unless STI
o Chlamydia, Neisseria gonorrhea (more common in younger males <35
years)
Symptoms:
 High fever
 Chills
 Suprapubic and perineal pain that radiates to back or rectum
 Signs and symptoms of a UTI
 Prostate is warm, extremely tender, and boggy
Labs:
 UA/Culture is definitive
 CBC shift to left (band cells) in UA, pyuria, hematuria
 Fractional urine x3
Treatment:
 Uncomplicated age <35, higher risk for STI:
o Ceftriaxone (Rocephin) 500 mg IM x 1 dose PLUS Doxycycline 100 mg BID
x 10 days

 Uncomplicated, lower risk of STI (Older than 35):

o Ciprofloxacin (Cipro) 500-700 mg BID or
o Levofloxacin (Levaquin) 500-750 mg QD x 10-14 days
Other meds:
o Stool softeners, analgesic, antipyretics
o Refer to urologist

Chronic Bacterial Prostatitis:

Bacteria:
 E. coli
Symptoms:
 Low grade fever
 Dysuria
 Urinary frequency
 Urgency
 Prostate exam NORMAL
Treatment:
 Ciprofloxacin 500 mg BID or
 Levofloxacin 750 mg QD for 4 weeks
o Alternative:
■ Bactrim DS x 1-3 months
 95

Acute Bacterial Epididymitis:

Symptoms:
 Adult to older male with acute onset of a swollen red scrotum that is painful
 Accompanied by unilateral testicular tenderness with urethral discharge
 Scrotum is swollen and erythematous with induration of the posterior epididymis
 Signs and symptoms of a UTI
 Green-colored purulent or serous clear discharge
 Positive Prehn’s sign:
o Relief of pain when the scrotum is elevated
Treatment:
 Uncomplicated age <35, higher risk for STI:
o Ceftriaxone (Rocephin) 500 mg IM x 1 dose PLUS Doxycycline 100 mg BID
x 10 days

 Uncomplicated, lower risk of STI (Older than 35):

o Levofloxacin (Levaquin) 500 mg QD x 10 days

Elevate the scrotum and use ice packs for pain. NSAIDs (ibuprofen 800 mg TID or
naproxen 500 mg BID)

Testicular Torsion:
 Extremely painful, swollen red scrotum
 May have acute hydrocele (severe edema)
 Severe nausea and vomiting
 Affected teste is higher/closer to the body
 Cremasteric reflex is missing (not present)
Dx:
 Doppler ultrasound with color flow study
 Blue dot sign:
o Blue colored nodule on superior aspect of testicle
Treatment:
 Send to ER

Hydrocele:
 Transillumination (affected scrotum will have a brighter and larger sized glow)

Testicular Cancer:
 Number one risk factor is cryptorchidism
 Ages 15-35 and after age 60
 More common in Whites

Varicocele:
 Feels like a bag of worms
 96

Erectile Dysfunction (ED):

Treatment:
 Viagra 50/100 mg. take one dose about 1 hour before sex PRN
 Avoid if concomitant nitrates, unstable angina, and some alpha blocker use

Other GU Conditions:
Peyronie’s disease:
 Painful crooked erections; palpable hard plaques beneath the skin
Balanitis:
 Infection of glans with candida
Phimosis:
 Foreskin can’t be pushed back from the glans penis
Priapism:
 Abnormal, painful prolonged erections lasting >4 hours
o Most common cause ED medication

Hernia:
Indirect hernia:
Background:
 Most common
 Intestines slip through the internal inguinal ring. Can drop down into the
scrotum (through the tunica vaginalis)
 Higher risk of incarceration
Direct hernia:
Background:
 Intestines protrude through a weak area in the fascia of anterior abdominal
wall (middle aged and older males)
 Hesselbach’s triangle
Treatment for both:
 Surgery

Strangulated Hernia (surgical emergency):

Symptoms:
 Gradual onset of abdominal pain that worsens into severe colicky pain
 Vomits bile or feculent (stool) fluid
 Unable to reduce hernia
 Incarcerated hernia feels warm and tender to touch
 On percussion: Tympanic
Treatment:
 Refer to ED or Surgery
 97

Women’s Health Review:

Birth Control:
Absolute Contraindications (Combined Oral Contraceptives):
Mnemonic: MY CUPLETS
 My: Migraines age >35; migraines with aura
 C: CAD or CVA
 U: Undiagnosed genital bleeding
 P: Pregnant/suspect pregnancy
 L: Liver tumor or active liver disease
 E: Estrogen-dependent tumor
 T: Thrombus or emboli
 S: Smoker age 35 or older

Monophasic OC:
 Same amount of estrogen and progesterone daily x 21 days
Biphasic OC:
 Same amount of estrogen daily for 21 days, but progesterone increased halfway of
the cycle
Triphasic OC:
 Three different doses of progesterone (changes every 7 days) for 21 days
Contraceptive transdermal patch (Ortho Evra):
 Patch effective x 1 week only. Replace patch same day weekly x 3 weeks
 Patch free for 1 week
NuvaRing:
 Insert once per month. Must be inside vagina x 7 days to be effective
Mini-pill or POP (progestin-only pills):
 Slightly less effective than regular OC’s
 Safe for breastfeeding women who can’t take estrogen
o If dose taken later than 3 hours; take it when you remember and use back-
up method for next 48 hours

Missed BC:
Missed 1 day of BC
■ Take 2 hormonal pills together that day then take one pill daily until
pill cycle is finished
■ If placebo pills missed not important
Missed 2 days of BC
■ Take 2 active pills ASAP
■ Then take 1 pill a day until you finish the 21 days of active pills
■ Skip placebo pills and start a new pill cycle
■ Advise to use condoms or abstain from sex until 7 consecutive days of
active pills are taken. Can consider Plan B if missed active pills in the
first week
 98

■ If took Plan B and vomits within an hour of taking it should take

another pill

BC Danger Signs:
Mnemonic: ACHES
 A-Abdominal Pain
 C-Chest pain
 H-Headache
 E-Eye problems
 S-Severe leg pain (DVT)

Plan B (Morning-After Pill):

 Contains levonorgestrel
 Used to prevent pregnancy
How to take:
 Take the 1st dose as soon as possible after the incident (within the first 72 hours)
o If the dose is vomited within 1 hour of taking, need to retake another pill
 Take 2nd dose within 12 hours of the first dose
 Side Effects:
o Nausea
 If no period at usual date, check for pregnancy. If pregnant will not cause birth
defects

Other Birth Control Methods:

IUD (intrauterine device):
 ParaGard:
o Effective up to 10-12 years and contains copper
 Mirena:
o Effective up to 5 years and contains progestin
Complications:
 Uterine infections, uterine perforation
o No IUD until infections are clear
Contraindications of IUDs:
 Recent infection of reproductive tract (severe cervicitis, PID, etc.) or recent
abortion
 Suspect or has STI
 Uterine or cervical abnormality
 Pregnant or suspect pregnancy
 Undiagnosed vaginal bleeding
Education:
 Check for missing or shortened string after each menses
o If missing order pelvic US
 99

Depo Provera (Progesterone):

 Lasts 3 months
 Not for women who want to get pregnant within 12-18 months
o Neither are IUD’s or Nexplanon
 Delayed return of fertility (few months to 18 months)
 Long-term use (>5 years): osteoporosis and weight gain. Recommendation: only 2
years or less

Diaphragm or Cervical Cap with Contraceptive Gel:

 Must be fitted by health provider and need a Rx
 Should not be felt by female if sized correctly
 Can leave in vagina up to 24 hours, must add additional spermicide after every act
of intercourse
 Leave on for at least 6 hours after sexual intercourse

Nexplanon (Etonogestrel):
 Use backup contraception for 7 days after insertion
 Effective for 3 years

Sperm inside the uterus is viable for up to 6 days after sex. The most fertile time is from day 8 to
day 19 (avoid sex at this time) if trying to not get pregnant naturally

Menstrual Cycle:
Follicular Phase:
 Days 1-14. The follicle develops (egg) and estrogen goes up
Day 14:
 Peak of luteinizing hormone (LH). Only job is to cause ovulation
 Egg is released and travels down to fimbriae
Luteal Phase:
 Days 12-28. Corpus Luteum starts to make progesterone

Birth Control (smokers aged 35 years or older or estrogen contraindicated):

Non-hormonal:
 Barrier-methods:
o condoms, diaphragm or cervical cap
 Copper IUD
Progestin only:
 Nexplanon, Depo-Provera
 Progestin-only pills (POP) aka mini pill

Dysmenorrhea (Menstrual Cramps):

Background:
 Uterine pain during the first few days of menstrual cycle caused by increased
level of prostaglandins
 100

Treatment:
 NSAIDs:
o Ibuprofen 400-600 mg every 4-6 hours or naproxen every 12 hours
o Ponstel 250 mg every 6 hours PRN
 Consider oral contraceptive pills

Uterine Leiomyomas (Fibroids):

Background:
 Fibroids are benign tumors of the uterus. May evolve into cancer called a sarcoma
(rare)
Symptoms:
 Middle aged Black woman complains of heavy menstrual bleeding (menorrhagia)
that is sometimes accompanied by low back pain
Imaging:
 Pelvic and Transvaginal US

Postmenopausal bleeding:
 ENDOMETRIAL BX
 If ovary is felt in an elderly female, must do a US to rule out ovarian cancer (OC)
o Ovaries should shrink in postmenopausal women

Contraindicated/Avoid in Pregnancy:
Live attenuated Virus Vaccines:
 Measles (Rubeola), Mumps, Rubella, Flumist, Shingles (Zostrix), Rotavirus, Oral
Polio

Quinolones (contraindicated <18 years):

 Ciprofloxacin, Ofloxacin, Levofloxacin, Moxifloxacin
o Affects cartilage and can cause tendon rupture

Trimethoprim-Sulfamethoxazole (Sulfa based drugs):

 Hyperbilirubinemia

Tetracyclines (Cat. D):

 Doxycycline, Minocycline
o Staining of tooth enamel

ACE Inhibitors/ARBs (Cat. D in 2nd & 3rd trimester):

 Captopril and Benazepril
o Fetal malformations

WET PREP is done on: BV, YEAST, TRICH

 101

Bacterial Vaginosis:
Symptoms:
 Strong fish like vaginal odor
 Off white thin and runny vaginal discharge coating the walls of the vagina
o No redness or irritation
Dx:
 Wet smear/prep
o Squamous epithelial cells with a large amount of bacterial coating
 KOH to cotton swab for whiff test (positive pH >4.5)
 Clue cells
Treatment:
 Metronidazole (Flagyl) BID x 7 days or vaginal gel at night x 5 days
 Alternative:
o Clindamycin vaginal cream at night x 7 days
Caution:
 Increased risk:
o PID, pre-term labor
 Disulfiram-like drug interaction if Flagyl combine with alcohol (severe nausea
and vomiting, headache, high BP, etc.)
 No need to treat partners not an STI

Candida Vaginitis:
Symptoms:
 Itching and burning of the vulva and/or vagina for several days
 Large amount of cottage cheese like discharge, pruritis, swelling, redness
Dx:
 Wet smear/prep
o Large # WBC (d/t inflammation), pseudohyphae and spores
Treatment:
 Clotrimazole or miconazole vaginal suppository OTC
 Diflucan 150 mg x1
 No need to treat partners not an STI

Trichomoniasis (STI):
Symptoms:
 Sexually active female complains of severe vulvar & vaginal pruritis with green
discharge
 On physical exam the vulva/vagina look irritated and reddened
 Cervical surface may have punctate hemorrhages/petechiae (strawberry cervix)
 Copious yellow to green frothy discharge
 Burning with urination
Dx:
 Wet smear/prep
o Look for protozoa with flagella and large amount of WBC (d/t
inflammation)
 102

Treatment:
 Flagyl 2 g x1; or 500 mg BID x 7 days
 Treat sexual partner

Benign Findings:
Cervical Ectropion:
 Glandular cells inside and around the os. Appears as bright bumps on the cervical
surface covered with clear mucus. Teens and younger girls have a larger
ectropion
Nabothian Cyst:
 Mucous retention cyst. Translucent or opaque whitish to yellow cyst on cervical
surface

Age to Start Pap Screening Screening Exam Screening Interval

Age 20 or younger Do NOT screen Do NOT screen
Age 21 to 29 Liquid-based cytology or Every 3 years
Conventional Pap
Age 30-65 Liquid-based cytology Every 5 years (if co-testing) or
with HPV co-testing Every 3 years
preferred or
Liquid-based cytology alone
Age >65 No screening If NO hx of CIN 2-3, AIS, or
cervical cancer within the last 20
years
Must have squamous epithelia cells and endocervical cells present in sample

Colposcopy: done on the cervix to obtain cervical/endocervical biopsy

Endometrial biopsy: for suspected endometrial hyperplasia/cancer (postmenopausal bleeding)

Atypical Squamous Cells of Undetermined Significance (ASC-US):

ASC-US ages 21-24:
 Repeat cytology/pap in 12 months as HPV testing is not recommended in age

ASC-US ages 25 and older:

 Order HPV DNA testing
o If positive but no oncogenic strain (#16 and #18) repeat cytology in 12
months
o If #16 and #18 present refer for colposcopy and cervical biopsy

High/Low-Grade Squamous Intraepithelial Lesions (HSIL/LSIL):

HSIL/LSIL ages 21-24:
 Colposcopy
 103

HSIL/LSIL ages 25 and older:

 Colposcopy/biopsy with LEEP

Perimenopause:
Symptoms:
 Hot flashes, night sweats, mood swings, insomnia, dysfunctional uterine bleeding
Treatment:
 Progesterone cream, SSRIs, exercise, soy isoflavones (soy milk, tofu)
Menopause:
 Defined as amenorrhea for 12 consecutive months (mean age 51 years; range 45-
55)
o Based on clinical signs not FSH value

Atrophic Vaginitis:
Background:
 Lack of estrogen affects the labia, vagina, and urethra
 Complaints of worsening vaginal dryness and painful sexual intercourse
Treatment:
 First Line: Lubricants
 If that doesn’t work can try topical estrogen
 If the patient has an intact uterus and is on estrogen add progesterone to prevent
hyperplasia of the endometrium

Osteoporosis:
 T-score -2.5 or less (at the hip)
Osteopenia:
 T-score of -1.1 to -2.4

Supplement with calcium 1200 mg with Vitamin D 800 units

Smoking cessation and weight bearing exercises: walking, yoga, Tai Chi, dancing,
strength training

 First Line:
o Bisphosphonates (Fosamax) or (Actonel) weekly dosing
■ Take in the AM alone with full glass of water
■ Must stay upright for 30-60 minutes after taking dose; can cause
esophagitis and perforation
 Monitoring:
o After 2 years of therapy, order DXA of hip and spine
 Contraindications:
o Esophageal motility disorders, history of PUD, CKD, esophagitis,
strictures
 104

SERM (selective estrogen receptor modulator):

Background:
 Ex: Tamoxifen: Blocks estrogen and are used to treat estrogen receptor positive
breast cancer
Adverse Effects:
 Hot flashes (most common), leg cramps, peripheral edema, increased risk of
gallbladder disease

Polycystic Ovarian Syndrome (PCOS):

Symptoms:
 Infrequent ovulation, amenorrhea/infrequent menses, infertility, excessive
androgen production, insulin resistance
 Starts at puberty/menarche
 Hirsutism, obesity, amenorrhea, oligomenorrhea, male-pattern alopecia, acne
Dx:
 Pelvic US (enlarged ovaries with follicular cysts “ring of pearls” appearance
Treatment:
 First Line:
o Low dose oral contraceptives
 If desire pregnancy
o Metformin
Risk:
 Obesity, hypertension, Type 2 DM, metabolic syndrome, hyperlipidemia, insulin
resistance, breast cancer, endometrial cancer, CAD

Fibrocystic Breast Disease:

Symptoms:
 Lumpy, thick, and tender breasts that worsen a few days before the menstrual
cycle and get better after menses start

Cyclical breast pain (Mastalgia):

Symptoms:
 Caused by hormonal fluctuations of the menstrual cycle
 Usually presents about a week prior to menses, is bilateral, and is most severe at
the upper outer quadrant of the breast (tail of spence)

Simple Fibroadenoma:
 Most common type of benign breast tumor

Infiltrating ductal breast cancer:

 Makes up 70-80% of invasive cancers (most common)

Nipple discharge:
 Considered pathologic if spontaneous, persists, or arises from a single duct,
contains gross or occult blood
o Send to lab for cytology testing
 105

Breast cancer:
 Do Ultrasound to differentiate between lesion vs cyst
 MAMMO and US are next steps

Physical Exam:
 Check for signs of breast cancer (peau de orange, dimpling, skin retraction,
symmetry and contour)
 Infiltrating lobular carcinoma can feel like diffuse thickening of breast tissue
(instead of a discrete mass)

Ruptured Ectopic Pregnancy:

Symptoms:
 Light to scant bleeding in 6-12 weeks gestation. Most common site of
implantation are the fallopian tubes
 Lower Abd/pelvic pain
 Intermittent cramping, if radiating to RIGHT shoulder think rupture
 Pain is worsened with SUPINE or with JARRING
Dx:
 US, elevated beta-hCG
Risk Factors:
 Previous ectopic pregnancy, tubal ligation, PID places patient at higher risk
Treatment:
 Refer to ER or call 911

Ovarian CA:
Symptoms:
 Middle-aged or older woman with vague symptoms of abdominal bloating or
abdominal discomfort, low-back pain, pelvic pain, dyspareunia, and changes in
bowel habits
 Unusual tiredness or fatigue
Exam:
 Should not ever be able to palpate an ovary in postmenopausal women
 Pelvic and intravaginal US
Risks:
 >50, early menarche, late menopause, obesity, family history, 1st preg. after 35, or
not ever being pregnant

Mammogram:
 Baseline at age 50 then every 2 years
 Age 75 older = don’t do
 Begin at age 40 for high-risk patients
 106

Sexually Transmitted Infections:

Neisseria Gonorrhea:
Symptoms:
 Purulent green discharge
 Men:
o Urethritis, epididymitis, prostatitis
 Women:
o Urethritis, mucopurulent cervicitis, endometritis/salpingitis/PID, friable
cervix
 Both:
o Proctitis, pharyngitis
 If disseminated disease:
o Migratory ARTHRITIS, synovitis, rash, fever, chills
Specimen:
 NAAT
 Alternative:
o GC cultures using Blood Agar medium (Thayer-Martin)
Treatment:
 Uncomplicated GC Infections (cervix, urethra, pharynx, rectum):
o Ceftriaxone 500 mg IM in a single dose
o Pregnant:
■ Ceftriaxone 500 mg IM in a single dose
 Complicated GC Infection (PID, epididymitis, prostatitis):
o Ceftriaxone 500 mg IM x single dose PLUS Doxycycline 100 mg BID x
10 days
Sexual Partner:
 Treat as complicated infection and have abstain from sex for 7 days

 *CDC recommends that if Gonorrhea is positive, the provider cotreat the patient
for Chlamydia as well. (Ceftriaxone plus Doxy)

Untreated Gonorrhea:
 In women:
o Leads to PID, abscess, ectopic pregnancy, infertility, can pass to baby
during delivery
 In men:
o Epididymitis, infertility

Chlamydia:
Background:
 Most common bacterial STI in the USA
Symptoms:
 107

 Usually, asymptomatic
 Can have scant clear mucus or cloudy white discharge
 Females:
o Cervicitis, endometritis, salpingitis, PID
 Males:
o Epididymitis, proctitis
 Both:
o Urethritis, pharyngitis, proctitis (from receptive anal intercourse)
 “Fitz-Hugh Curtis Syndrome”
Specimen:
 Males:
o Urine
o Or NAAT
 Females:
o Vaginal swab equal to cervical specimen (NAAT)
 Alternative:
o GC cultures using Blood Agar medium (Thayer-Martin)
Treatment:
 Azithromycin 1 gm PO x 1 or Doxycycline 100 mg BID x 7 days

Pregnant women:
 Azithromycin 1 gm PO x 1 or Amoxicillin 500 mg TID x 7 days
o Test of cure 3 weeks after completion

Sexual Partners:
 Azithromycin 1 gm PO x 1
 Abstain from sex for 7 days

Proctitis or Proctocolitis:
Background:
 CDC recommends annual screening of male MSM. History of unprotected
receptive anal intercourse. May have a new sexual partner <60 days
Symptoms:
 Acute onset of purulent rectal discharge, anorectal pain, and tenesmus (frequent
urges of passing stool)
Lab:
 NAAT
Treatment:
 Ceftriaxone 500 mg IM x single dose

Pelvic Inflammatory Disease (PID):

Symptoms:
 Diagnosed based on clinical symptoms
 108

 Sexually active female <24 years with new onset of one-sided pelvic pain with
mucopurulent vaginal discharge
 May have new sexual partner <60 days
 Complains of pelvic pain with jarring when walking (shuffles gait to lessen pain)
 Pain with intercourse (dyspareunia). Positive cervical motion tenderness
with/without adnexal pain
Labs:
 Rule out pregnancy
 Chlamydia and gonorrhea using NAAT
 HIV testing
 Syphilis (RPR or VDRL)
PID criteria to diagnose:
 Cervical motion tenderness
 And/or uterine tenderness
 And/or adnexal tenderness
Treatment:
 Ceftriaxone 500 mg IM x one dose PLUS Doxycycline 100 mg BID x 14 days
PLUS Metronidazole 500 mg BID x 14 days
o Treat symptomatic PID even if GC are negative
o Follow up with bimanual exam in 2-3 days
o Male sexual partners should be evaluated, tested, and treated for
chlamydia and gonorrhea (they are usually asymptomatic)
Complications:
 Infertility, ectopic pregnancy, pelvic abscess
 Fitz-Hugh Curtis Syndrome
o Rare complication of PID. Infection of the liver capsule that causes
adhesions. Complains of RUQ pain that is worsened by coughing,
laughing and pain may be referred to the right shoulder

Expedited Partner Therapy:

 Clinical practice of treating sexual partners of patients diagnosed with chlamydia
and/or gonorrhea by providing prescriptions or medication to the patient to take to
his/her partner without the provider first examining the partner

Syphilis:
Symptoms:
 Primary Stage:
o Chancre that spontaneous resolves in 3-6 weeks
 Secondary Stage:
o Rash and Condyloma Lata (painless genital chancre)
■ Test Tip: Condyloma Lata the “Lata” has an L just like Syphilis
whereas genital warts Acuminata does not
Testing:
 First tests are RPR & VDRL which are SCREENING tests
 If reactive then confirm with FTA ABS
 109

o If both positive pt. has syphilis

Treatment:
 Penicillin G
Reaction:
 Jarisch-Herxheimer Reaction
o Common immune reaction after starting syphilis treatment. Myalgias,
fever, headache, tachycardia, and hypotension
o Goes away on its own

Human Papillomavirus (HPV 6 & 11):

Background:
 CDC states that HPV is the most common STI in the US
 Causes genital and perianal warts (condyloma acuminata)
 Can cause cancers of the cervix, vulva, vagina, penis, anus, and oropharyngeal
area
Oncogenic strains:
 HPV 16 and 18
Screening:
 Age 21 years with cervical cancer screening
 Lab: HPV DNA testing
Treatment:
 Trichloroacetic acid, Condylox, Aldara, Veregen, cryotherapy, surgical removal
 What is done if excess acid is applied?
o Should be removed ASAP by using talc powder or sodium bicarbonate
 Treatment acceptable during pregnancy
o Cryotherapy, TCA or BCA, and surgical excision. Avoid chemicals

Gardasil:
 Age 11-12 first dose (can start as early as 9 years):
o Only need 2 doses if started series before 15th birthday
■ Give 2nd dose 6-12 months after first dose
 Age 15-45 and immunocompromised:
o Need 3 doses (0, 1-2, and 6 months apart)

Herpes Simplex (HSV-1 and HSV-2):

 HSV-1:
o Oral infection
 HSV-2:
o Genital infection
Symptoms:
 Erythematous papules that are itchy, have burning, and tingling
 Will have recurrent outbreaks
 Primary episode is more severe and can last 2-4 weeks
Dx:
 Gold Standard: RPR assay (Herpes Viral Culture) for both 1 & 2
 110

Treatment:
 First outbreak:
o Acyclovir 400 mg 3x/d for 7-10 days
■ CHEAPEST medication
 Episodic:
o Try to start within 1 day of lesion (pt may feel start of prodromal
symptoms)
■ Acyclovir BID or TID x 5 days

Human Immunodeficiency Virus (HIV):

Risk:
 Unsafe sex, MSM, injection drug use, blood products 1975-1985, breastfed infant
(positive mother)
HIV Testing:
 HIV-1/HIV-2 combination antibody/antigen test
o Checks for both HIV-1/HIV-2 antibodies and p24 antigen
PrEP:
 For people who don’t have HIV but are at a very high risk of getting HIV
take Truvada QD to prevent contracting the virus
PEP:
 Post exposure prophylaxis:
o Use of antiretroviral drugs after a single high-risk event to stop HIV
seroconversion
o Must be started ASAP to be effective and always within 72 hours

Pneumocystis Jiroveci Pneumonia (PCP):

Normal CD4 lymphocyte count:
 500-1500/mm3
 Check CD4 every month if on ART (antiretroviral therapy)
When CD4 <200 cells/uL:
 Prophylaxis for PCP pneumonia
o TMP-Sulfamethoxazole (Bactrim), then dapsone, then pentamidine in this
order
AIDS:
 HIV infection with CD4 count <200 cells/mm3
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Women’s Health (Pregnancy/Childbirth):

Pregnant (5th disease):
 Teratogenic on baby

Positive signs of pregnancy:

 Things done by health care provider:
o FHR HEARD
o US and a baby is seen
Probable signs of pregnancy:
 Goodell’s sign; cervical softening
 Chadwick’s sign; blue coloration of the cervix and vagina
 Hegar’s sign; softening uterine isthmus
 Enlargement of uterus
 Ballottement
 Positive pregnancy test
Presumptive signs of pregnancy:
 She is PRESUMING that she is pregnant and least objective signs
 Amenorrhea
 Nausea/Vomiting
 Breast changes (swollen and tender)
 Fatigue
 Urinary frequency
 Slight increase in body temperature
 Quickening; mother feels the baby’s movement for the first time

Trimesters:
 1st 1-12 weeks
 2nd 13-26 weeks
 3rd 27-end

Appointment schedule:
 0-28 q4w. 28-36 q2w. 36 till end q1w

Naegele’s Rule:
 Method 1: LMP + 9 months and add 7 days
 Method 2: LMP - 3 months and add 7 days

Placenta Previa:
Symptoms:
 2nd-3rd trimester new PAINLESS vaginal bleeding worsened by intercourse
 Blood is bright red
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 Uterus soft non-tender

Treatment:
 If cervix is not dilated, treatment is strict bed rest
 Administer IV MAG IF THERE IS UTERINE CRAMPING
 Do not insert anything into the vagina/rectum
 If dilated cervix then deliver via c-section

Placental Abruption:
Symptoms:
 Late third trimester, sudden PAINFUL vaginal bleeding
 Uterus feels hard (hypertonic)
 Dark red bleeding. In severe cases deliver

Preeclampsia:
Symptoms:
 Late third trimester >34 weeks
 Sudden onset of headache, visual abnormalities, pitting edema
 Edema easily seen on face, eyes, fingers, sudden rapid weight gain within 1-2d
(>2-4lb/wk.)
 RUQ pain
 BP >140/90. Protein 1+, decreased urine
 IF SEIZURES THEN ECLAMPSIA. Earliest is at 20 weeks that they can have
this. Lay on left side
Treatment:
 Only “cure” is delivery of fetus or baby

UTI:
 103 wbc is considered positive in pregnancy with symptoms. Non-pregnant people
it’s 105
 MEDS: Macrobid (not for 3 trimester) Augmentin, Amoxicillin, Cephalexin,
Fosfomycin

Mastitis:
Symptoms:
 Red, firm, tender area, fever, chills, flu like symptoms
 Basically, this is cellulitis of the breast
Treatment:
 Dicloxacillin 500 mg, or Keflex 500 mg QID x 10-14 days
 If you suspect MRSA, do Bactrim BID x 10-14 days or
 Clindamycin 300 mg QID x 10-14 days
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 Fundal height 12 weeks above symphysis pubis

 Fundal height 16 weeks between symphysis pubis and umbilicus
 Fundal height at 20 weeks is at umbilicus
 2 cm more of less from # of wk. gestation is normal if more or less order US

 1300 of calcium during pregnancy

AT 16 WEEKS TEST FOR AFP:

 Low:
o Down syndrome
 High:
o Neural tube defects

TRIPLE SCREEN:
 AFP, BETA HCG, ESTRIOL
o Diagnostic test for genetic anomalies is chromosome testing

QUAD SCREEN:
 The triple screen PLUS INHIBIN A
o More sensitive than AFP alone but higher rate of false positives
 Gold Standard for genetic disorders is testing of fetal chromosomes/DNA

GBS (Group B strep):

 35-37 weeks swab

Give RhoGAM at 28 weeks. The Coombs test detects rh antibodies in the mother (indirect) and
the infant (direct). 2nd dose is 72 hours or sooner post-delivery. IF RH NEG MOM

Can always do an ABD ultrasound with vaginal bleeding but NOT A VAGINAL
ULTRASOUND
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Children and Older Kids:

Girls:
 Growth spurt earlier than boys (about 2 years earlier)
 Most of height is gained before menarche
 Precocious puberty before 8; delayed if no breast development by 12 years
 Breast budding to 1st menses is 2 years

Tanner Staging Girls:

II: Breast bud starts
III: One breast mound
IV: Secondary breast mound
 Think of the “V” as a breast with each tip having a mound on the tip

Boys:
 Peak growth velocity is in mid-adolescence

Tanner Staging Boys:

II: Testes (only) enlarge
III: Penis elongates
 Think of III as all the lines pointing down with elongation
 Longest finger
IV: Penis starts to widen
 Think of the V as widening

III
II Girls: in pink

1 breast mound Boys: in blue

IV
Breast bud starts
2 nd breast
mound Only need to remember stages II-
Penis elongates IV

Testes enlarge Penis starts to widen

I V

Baby Adult
 115

Psychosocial Development:
 Can think in abstracts “shades of gray”
 Logical thinking/plans
 Friends and peers are valued highly
 Attempts to separate from parents (their values vs parents)
 Taking more risks and more independent
 More compassion/empathy than in childhood

Psychosocial Theorist:
 Freud
o Genital Stage (start of puberty to adult) final stage, sexual urges and
interest, looks/finds sexual partner/mate

Legal Terms:
Minor:
 Someone under the age of 18
Age of Consent (age of majority):
 Aged 18 years or an emancipated minor (legally married, armed forces,
court/legal emancipation)
Emergency care:
 Minors may consent only if treatment delay (to get parental consent) will
endanger their life/health

Emancipated Minor:
 Gain all the legal rights of an adult before reaching the age of 18. Can sign
legally-binding contracts, own property, or sign consent for medical care
 Who is considered an emancipated minor?
o Minors in the armed forces (age 17 years is minimum age to join military)
o Legally married minors (need parental consent to marry a minor)
o Emancipated minor status obtained from a court of law

No parental consent needed for:

 Contraception but not sterilization
 Diagnosis/management of pregnancy
 Treatment of STIs
o Examples:
■ Treating a cold, dysmenorrhea, vaccinations (BUT not for treating STIs)
■ Any medication (except contraception/birth control pills)
■ Sports participation, sports physicals, others

Adam’s Forward Bend Test:

Screening:
 Screening for scoliosis
How to conduct:
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 Have patient bend forward with both arms hanging/free or bend forward
and touch their toes
Assess:
 Look for any asymmetry. One side will be higher (scapula), curvature of ribs
Symptoms:
 Idiopathic scoliosis is painless and asymptomatic
 There will be a lateral curvature of the spine
 More common in girls
 One hip and/or shoulder is higher than the other
Treatment:
 Cobb angle less than 20O
o Observation
 Cobb angle 20O- 40O
o Bracing
 Surgery for curves > 40O

Osgood-Schlatter Disease (OSD):

Symptoms:
 Knee pain in young adults from overuse
 Repetitive stress pain, tenderness, swelling at the tendon’s insertion site
 Tibial tuberosity
 Rule out avulsion fracture if there is an acute onset; order a lateral x-ray (optional)
Treatment:
 RICE
 Tylenol or NSAIDS for pain
 Avoid sports and excessive exercise
 Usually stops when growth stops

Benign Gynecomastia of Adolescence:

Symptoms:
 Asymmetric breasts that are tender
 Round, firm, or rubbery mound under each areola/nipple that is mobile and
discrete
 Tenderness on breast palpation is very common

Pseudo-gynecomastia:
Symptoms:
 Adipose tissue
 Not true gynecomastia (feels soft since it is fatty tissue and not rubbery)

Slipped Capital Femoral Epiphysis (SCFE):

Symptoms:
 PAINFUL LIMP
 Most common adolescent hip abnormality
 Spontaneous dislocation of femoral head
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 Pt complaints of hip pain or knee pain that is relieved by rest and limping
 Will have a shortening of the leg if not treated
 No ambulation is permitted because this will cause irreversible damage
Dx:
 X-ray using AP lateral frog-leg position
Treatment:
 Surgery

Legg Calve Perthes Disease:

Symptoms:
 PAINLESS LIMP
 Aseptic/avascular necrosis of the femoral head
 Could be due to vascular disruption
 Insidious onset of KNEE PAIN that migrates up to the groin
 AFEBRILE
Dx:
 X-ray of femur and hip
Treatment:
 Surgery, bracing/casting

Retinoblastoma (Leukocoria):
 Hallmark sign white spots in eye. Cancer
Dx:
 Red light reflex

Klinefelter Syndrome:
Symptoms:
 More female traits in males due to an eXtra X chromosome
 One of the primary causes of hypogonadism (deficiency in testosterone)
 Testicles are small and firm with small penis. Tall stature, wider hips reduced
facial and body hair, and higher risk of osteoporosis
Treatment:
 Testosterone replacement and fertility treatment

Turners Syndrome:
Symptoms:
 Females with ONLY ONE X chromosome
 Webbed neck, lymphedema (hands and feet), high-arched palate, and short fourth
metacarpal
 Short stature, ovarian failure, cardiovascular and renal issues, ear malformations,
and amenorrhea

#1 cause of death: motor vehicle crashes

#2 suicide
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Geriatrics/Gerontology:
Changes Related to Aging:
 Thinner epidermis/dermis and subcutaneous layer
 Thinner/drier skin and less elastic (less collagen/elastin)
 Increased risk of skin tears and slower wound healing

Senile Purpura (Bruising):

 Purple macules or patches that are well-demarcated (especially on the dorsum of the
forearm)

Presbyopia:
 Loss of near vision starts in the 40’s (“My arms are too short”)
 Need more light to read and see things
 Lens become stiffer and denser
 Pupils are slower to react (slower accommodation)
 Decrease in depth perception and night vision
 Drier eyes (less tear production)

Cataracts:
 Opacity of the lens of the eye

Presbycusis (sensorineural hearing loss):

 Starts at age 50
 Affects the inner ear
 High frequency hearing is lost first (talking)

Arcus Senilis or Corneal Arcus:

 Cholesterol & Calcium deposits
 Opaque grayish-white ring located on the periphery of the cornea that does not affect
vision

S4 heart sound:
 Can be a normal finding in the elderly if it’s not associated with valvular disease or HF

 Baroreceptors are less sensitive which causes a blunted BP response. There is a

higher risk of postural hypotension and syncope especially if on antihypertensives

Immune System:
 Humoral immunity (B-cells, IgG) are mostly intact and affected less by aging, but
cellular immunity (T-cells, and macrophages) are less intact
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Kidneys:
 Renal size and mass decrease by 25-30%. Starting at age 40, the GFR starts to decrease.
By age 70 up to 30% of renal function is lost
 Renal clearance of drugs is less efficient
 Serum creatinine can be in the normal range even if renal function is markedly reduced

Immunization for Older Adults:

 Influenza Vaccine
o Inactivated flu vaccines, quadrivalent and trivalent
■ Start at the end of October annually and give IM
o Fluzone High-Dose vaccine (4 times higher dose)
■ Give if age 65 or older
 Tetanus Vaccine
o Tdap or Td
■ Substitute Tdap for one Td booster (once in a lifetime)
 Shingles Vaccine
o Shingrix (RZV)
■ Age 50: two doses 2-6 months apart regardless of previous history of
shingles or history of Zostavax (ZVL) vaccination (wait 2 months before
giving RZV)
 Pneumococcal Vaccine
o PPSV23 (Pneumovax)
■ Age 65 or older. If given before age 65 years, repeat in 5 years
o PPV13 (Prevnar)

Dementia:
 Irreversible
 Gradual onset
 Duration: lifetime
 Slow progressive decline of mental and functional capacity
 Short term memory declines- early sign
 Episodic memory affected first (memory of recent events)
Cause:
 Alzheimer’s (most common), CVA, Parkinson

Delirium:
 Reversible (remove cause)
 Rapid onset
 Duration: brief
 Incoherent and confused
 Agitation, excitement, disorientation, delusions
Cause:
 High fever, infections, shock, drugs, alcohol, dehydration
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Anticholinergic Adverse Effects:

 Mnemonic: SADCUB
 S-Sedation
 A-Anorexia
 D-Dry mouth
 C-Confusion and Constipation
 U-Urinary Retention
 B-BPH

MMSE:
 Used to evaluate confusion and dementia. (Orientation, Immediate recall, Attention and
Calculation, Writing and Copying)
 0-10 severe, 10-20 moderate, 20-25 mild, 25-30 normal. <24 highly suggestive of
dementia
 The lower your score the higher chance dementia is present
 Ability to manage a calendar (executive function)

Mini-Cog Test:
 Screening tool for cognitive impairment
 Step 1: Three-word recognition (1 point for each word)
 Step 2: Clock drawing (score normal or abnormal)
 Step 3: Three-word recall
o Score range 0-5
o Dementia if score 0-2 points
o No dementia if score 3-5

Alzheimer Disease (AD):

Symptoms:
 #1 cause of dementia
 Insidious onset
 Due to buildup of plaque, amyloid and neurofibrillary tangles in the brain
 Impaired memory of recent events (episodic memory)
 Aphasia, Apraxia/dyspraxia (difficulty doing known motor tasks), Agnosia
(difficulty recognizing familiar things/faces)
Terminal:
 Total care, incoherent speech to mute, incontinent, wheelchair bound. Usually
die from complications (pneumonia, sepsis, hip fractures)

Depression, aggression, restless, and/or anxiety:

 SSIRs are preferred for depression/anxiety:
o Celexa (citalopram) or escitalopram (Lexapro)
■ Can use sertraline (Zoloft) as well but first two better options
 SNRI:
o Wellbutrin (bupropion)
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■ More energizing
 Remeron (mirtazapine):
o For depression, can stimulate appetite
 Sleep/Insomnia:
o Ambien, Lunesta, Sonata are preferred
 Agitation (short term):
o Lorazepam (Ativan), Clonazepam (Klonopin)
 Severe symptoms of hallucinations, aggression, agitation, paranoia:
o 2nd generation antipsychotics (Risperidone, Seroquel, Zyprexa)
■ Increases risk of death in elderly with dementia

Activities of Daily Living (ADLs):

 Self-care tasks such as eating, toileting, bathing, putting on clothes, grooming, walking,
etc.

Instrumental Activities of Daily Living (IADLs):

 Managing finances, paying bills, using the phone, housework, shopping, preparing meals,
driving a car or using transportation

Parkinson’s Disease (PD):

Symptoms:
 Elderly pt. with bradykinesia, cogwheel rigidity, pill-rolling tremor, a tremor that
worsens with REST, mask-like stare, and a slow shuffling gait
Dx:
 Based on clinical sings/symptoms
 Rule out secondary causes
Treatment:
 PT, OT, balance training, exercise
 Levodopa (carbidopa/levodopa) BID to TID

Stress Incontinence:
Symptoms:
 Precipitated by sneezing, laughing, coughing, and heavy lifting
 Leaking a small amount of urine
Cause:
 Due to estrogen deficiency and previous surgery
Treatment:
 Assess lifestyle
 Pelvic floor muscle training (Kegels) 30-45 Kegels per day with 3 sessions per
day

Urge Incontinence (most common):

Symptoms:
 Urgency, frequency, and the sudden strong urge to urinate
 Will dump large amount of urine
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Cause:
 Due to bladder detrusor muscle weakness
Treatment:
 Oxybutynin (Ditropan) patch or oral
o Anticholinergics contraindicated in narrow angle glaucoma, bladder outlet
obstruction (BPH), etc.
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Health Promotion and Health Screening:

Primary: Prevention of disease, accidents
No disease or Accident is present yet
 Disease prevention (immunizations)
 Laws/Programs for public health (clean water)
 OSHA laws for workplace safety
 EPA laws for environmental safety (car emission levels)
 Health promotion programs
o Prevention of youth violence (mentoring, youth club, etc.)
 Personal protection (helmets, housing, seatbelts, airbags)
 Personal action to avoid disease (exercise, good diet, etc.)

Secondary: Detect disease as early as possible

Disease has started so you’re trying to detect it as early as you can
 ALL screening for disease
 All screening tests (Pap, PSA, PPD, mammogram, depression, anxiety, etc.)

Tertiary: Limit further disability (major damage to body already happened (Stroke, MI)
 ALL rehab: cardiac rehab, PT, OT, speech therapy
 Education on disease self-management (diabetes)
 Education about Rx meds (side effects)
 Education using equipment: wheelchairs, cane
 Support groups (AA, HIV)
 Counseling/therapy for disease

USPSTF Disease Screening:

Breast Cancer (2016):
 Females age 50-74 years
 Routine mammogram screening every 2 years (biennial)
 75 and older: not recommended
 High risk:
o 50 and older, prolonged estrogen exposure, early menarche, late
menopause, nulliparity, late first pregnancy, obesity, family history

Prostate Cancer (2018):

 Men aged 55-69 years
 PSA should be individualized
 USPSTF does not recommend automatically screening all men for prostate cancer
 Age 70 and older: against screening
 High risk:
o African American, 1st degree relative (father/brother) with prostate cancer
before age 60 or who died of prostate cancer before age 75
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Colorectal Cancer (May 2021):

 Baseline: age 45 years
 Age 45-75: recommend screening
 Age 76 to 85: selectively offer screening
 Methods:
o Colonoscopy, Flexible sigmoidoscopy, stool test (FIT and sDNA-FIT)
such as Hemoccult once a year/annually
 High risk:
o Inflammatory bowel disease (ulcerative colitis, Crohn’s disease), familial
polyposis, polyps in the colon, 1st degree relative with colon cancer,
smokers
o IBS does NOT increase risk of colon cancer

Lung Cancer (March 2021):

 Age 50-80
 20 pack year history or who currently smoke or quit within the past 15 years
 Annual screening with low-dosed computed tomography (LDCT); helical CT
o Stop screening if person has not smoked for 15 years or develops health
condition that substantially limits life expectancy

Prediabetes and Type 2 Diabetes (August 2021):

 Screening recommended for persons who are overweight or obese (BMI ≥ 25)
 Asymptomatic ages 35-70
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Other:
Memorize these lab values for ANCC; numbers will be given to you on AANP:

 WBC >11.0 (normal 4.0-10.5 x103/ml)

o Elevated with infections (especially bacterial), trauma, burns, etc.
 Neutrophils >70% (normal 56%-62%)
o Elevated with infections (especially bacterial)
 Lymphocytes >10%
o Elevated usually with viral infections, mono, and lymphoma
 Eosinophils
o Elevated with allergies or atopy, intestinal worms
 Platelets <150,000 (normal 150,000-450,000/mm3)
o Decreased with blood clotting disorders, DIC, etc.
 Creatinine >1.3 mg/dL
 Potassium <3.5 or >5.5
 TSH >5 mIU/L
o Normal 0.4-4.2 mIU/L

Carotid Bruit:
 Caused by carotid stenosis (cholesterol plaque accumulation)

Patient forgot to start Thanksgiving dinner and husband states she has trouble
remembering tasks and trouble with organization. This is indicative of:
 Loss of executive function
 Executive function includes the ability to manage a calendar, organizing, planning
(getting things started), multitasking, processing/storing information

Patient with atopic dermatitis would be at risk for what other conditions?
 Asthma, allergic rhinitis, multiple allergies
 Atopic dermatitis (eczema) is marked by extremely pruritic rashes on hands, flexural
folds (antecubital/popliteal space), and neck
 Rash is exacerbated by stress and environmental factors
 Rash appears as multiple small vesicles that rupture and leave painful, bright red, weepy
lesions that become lichenified from chronic itching; fissures can form and can be
infected with bacteria
Treatment:
■ Topical steroids (1st line); systemic antihistamines; skin lubricants; hydrating
baths

Patient with history of PID has increased risk for?

 Infertility
 Cervical motion tenderness indicates PID
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 Treat symptomatic PID even if GC and chlamydia tests are negative

 Follow up with vaginal bimanual exam in 2-3 days to make sure symptoms are improving

Old lady with weakness on 2 HTN meds, 2 DM meds, vitamins:

 Polypharmacy
 Hypotension
 Hypoglycemia

Wilm’s tumor:
 Nephroblastoma
 Asymptomatic abdominal mass that extends from flank toward midline
 Nontender, smooth mass that rarely crosses midline of abdomen
 Higher incidence in black, female children
 Peak age 2-3
 Most common renal malignancy in children
 When performing PE, palpate gently to avoid rupturing renal capsule
 Initial test is abdominal ultrasound

Baby with UTI – follow up?

 Renal and bladder ultrasound (RBUS) for all infants 2-24 months for first febrile UTI

Bumps start on face or trunk and spread to rest of body:

 Varicella
 Classic presentation – pruritic vesicular lesions in different stages of development and
healing

Infant had 2 episodes of RSV/bronchiolitis; now presents with fever, cough, wheezing;
differentials do not include:
 Foreign body

Most common bug for otitis media:

 Streptococcus pneumoniae
 Treatment – amoxicillin is gold standard for all ages; if recent amoxicillin use or failed
amoxicillin therapy, consider Augmentin

Most common cause of death in women:

 Heart disease
 Heart disease is also the most common cause of death in men

Lab test for Fifth Disease (erythema infectiosum):

 Parvovirus B19
 Diagnosis is usually made based on clinical presentation – “slapped cheek” – instead of
lab test
 127

 More common in children

 Contagious through respiratory secretions
 Symptoms include fever, headache, runny nose, rash

Patient complains about upper arm tremor that seems to be hereditary; treatment?
 Likely essential tremor
 Treated with beta-blocker (Propranolol 60-320 mg per day)
 Alternative treatment is primidone (50-1000 mg per day)

Highest suicide rates:

 Age: 45-54 and >80
 Race: White
 Sex: male (females attempt more often, but males have a higher success rate)
 Risk factors: loss of spouse; history of attempted suicide; family history of suicide;
mental illness; bipolar; depression; history of abuse; terminal or chronic illness; chronic
pain; substance/alcohol abuse; significant loss (job, friend, divorce, death of someone
close); plan to use gun

Fructosamine Test:
 Similar to Hemoglobin A1c
 Indicate the average level of blood glucose control over the past 2-3 weeks
 Increased level associated with prolonged hyperglycemia for 2-3 weeks prior to testing
 Higher the level, poorer the degree of the glycemic control
 Trend from high to normal may indicate treatment regimen is effective
 Not used for screening

What should be done before starting a statin?

 Baseline LFTs
 Statins affect CYP450 system and increases risk for rhabdomyolysis and drug-induced
hepatitis
 LFTs should be monitored periodically (more frequent for higher doses)

CDC recommendation on screening for Hep C:

 Adults born between 1945 and 1965
 Current or former IV drug users (even if use was only once and many years ago)
 Persons who have HIV infection
 Persons who have persistently abnormal ALT
 Persons who received blood, blood components, or organ transplant before July 1992
 Known exposure (needlestick, child born to HCV+ mom)

Patient with fever of 102 for 2 days and blood coming from ear?
 Ruptured TM

Degenerative joint disease treatment (OA):

 Exercise (swimming, walking, biking)
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 Lose weight
 Stop smoking
 First line medication – acetaminophen (Tylenol)
 Alternative therapies – glucosamine, SAM-e, acupuncture, Tai Chi

Acne Rosacea presentation:

 Light-skinned adult with Celtic background (Irish, Scottish, English); usually blonde/red
hair and blue eyes
 Papules and pustules around nose, mouth, and chin
 Facial redness, especially in central part of face
 Patient blushes easily
 May have red eyes, dry eyes, or chronic blepharitis
 Treatment includes topical metronidazole gel

Scaphoid fracture still having pain:

 Repeat x-ray, splint wrist, refer to surgeon
 Scaphoid fractures may not show on initial x-ray
 Patient usually has history of falling forward on outstretched hand
 Common complaint is deep, dull wrist pain that worsens with gripping or squeezing
 High risk of avascular necrosis

Medication that can cause CHF:

 NSAIDs
 Diabetes medications (glitazones)
 Calcium channel blockers/beta blockers
 Cancer medications

Signs/symptoms of CHF:
 Dyspnea/tachypnea, fatigue, dry cough, edema (feet and ankles), bibasilar crackles, S3
heart sound, resting tachycardia, diaphoresis
 Early signs/symptoms involve heart and lungs
 Later signs/symptoms involve periphery

Elderly lady with beefy red maceration under breast:

 Likely superficial candidiasis – superficial skin yeast infection promoted by increased
warmth and humidity, friction, and decreased immunity; generally, occurs in
intertriginous areas (under breast, axillae, abdomen, groin, and web spaces between toes)
 Treatment – nystatin powder/cream; OTC topical antifungal; keep skin dry and aerated

Patient with history of HTN and stroke now having memory loss; indicative of?
 Vascular dementia

Gravida 4 patient, hasn’t given birth in 5 years and is producing milk; common cause of
galactorrhea?
 Too much prolactin is most common cause
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 Other causes include certain medications/drugs (sedatives, antipsychotics,

antidepressants, antihypertensives, opioids, cocaine, marijuana, birth control pills, herbal
supplements, spironolactone); pituitary tumor; hypothyroidism; CKD; excessive breast
stimulation; spinal cord injury; nerve damage to chest wall

Five-year-old child who was potty trained at age 3; has been soiling himself for 3 months:
 Likely encopresis – involuntary soiling of stool in a child 4 years or older
 As stool accumulates in rectum, enlargement can result in loss of sensation, loss of urge
to defecate, internal anal sphincter relaxes, then stool leaks out
 Constipation is underlying cause 80% of the time
 4 times more common in males – in females, investigate sexual abuse
 Management – laxative for initial cleansing, behavior changes (toileting habits), dietary
changes
 Goal is one soft stool per day

Signs of dehydration in infant:

 Sunken fontanel, decreased frequency of urination, no tears when crying, dry/sticky
mucous membranes, lethargy, irritability

Contraindications for taking an ACE inhibitor:

 Moderate to severe kidney disease
 Renal artery stenosis
 Previous angioedema associated with ACE

Breast changes in elderly:

 Breasts lose fat, tissue, and mammary glands
 Breasts can become lumpy – from benign fibrocystic changes or from breast cancer
 Breasts can become elongated, stretched, and flattened in appearance

Epiglottitis:
 Symptoms – acute onset of high fever, chills, toxicity; child complains of severe sore
throat; drooling; child won’t eat or drink; may have muffled (“hot potato”) voice;
anxiety; may present with hyperextended neck with open-mouth breathing; may notice
stridor, tachycardia, tachypnea
 Usually occurs between ages 2 and 6
 Medical emergency (call 911)

Kawasaki Disease:
 Symptoms - onset of high fever (up to 104O) and enlarged lymph nodes on neck; bright
red rash (more obvious in groin area); conjunctivitis; dry, cracked lips; “strawberry
tongue,” swollen hands and feet; after fever subsides, skin peels off hands and feet
 Treatment – high-dose aspirin and gamma globulin
 Occurs most commonly in children under age 5; resolves in 4-8 weeks but may have
serious sequelae such as aortic dissection, aneurysms of coronary arteries, and blood clots
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 Close follow up with pediatric cardiologist for several years

Testing for pinworms:

 Scotch tape test
 Apply scotch tape on the anal area in the morning before showering, then transfer the
tape to a slide and take to the health care provider who will check the tape for eggs
 The worms come out at night to lay eggs in the anal area – that’s why the morning is the
best time to test
 Scotch tape test will need to be done several days in a row as females do not lay eggs
everyday

Neuroblastoma:
 Painful abdominal mass that is fixed, firm, irregular, and frequently crosses the midline;
the most common site is the adrenal medulla; about half of patients present with
metastatic disease; may be accompanied by weight loss, fever, Horner’s syndrome
(miosis, ptosis, anhidrosis), periorbital ecchymoses (“racoon eyes”), bone pain,
hypertension; most are diagnosed in children between ages 1 and 4; elevated urinary
catecholamines and anemia; initial imaging is ultrasound; refer to nephrologist

Child in with fever and otitis media; has appointment in 2 weeks for 12-month shots;
mom wants to cancel that appointment and get shots today; what do you tell mom?
 Vaccines scheduled for 12 months visit generally include MMR and varicella – these
cannot be given before 12 months of age

 Amiodarone and Simvastatin have a huge risk for Rhabdomyolysis.

Anticoagulant such as Warfarin for Afib. Starting on someone over the age of 70 years on 2.5
mg not 5 mg which is dose for ppl under 70.

INR goal 2-3.

INR goal for synthetic/prosthetic vales is 2.5-3.5

Do not give Vit K dose unless INR at 5.0 or above, hold a dose.

Anterior Wall MI or anterior STEMI is the most common and serious type of MI. EKG
includes ST segment elevations in V2 and V4, and Q waves. Wide QRS complex resembles
a tombstone.

Grapefruit juice/grapefruit:
 Do not mix with statins and CCB will cause high blood levels of the drugs
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Levels of Evidence:
 Best level of evidence:
o Randomized controlled trials/experimental studies gathered by systematic reviews
using Cochrane, PubMed, CINAHL, etc.
o Treatment guidelines are based on EBM
 Second level of evidence:
o Case-control study
o Case series
o Case reports
o Chart review
 Worse level of evidence:
o Expert opinions, editorials can be biased and subjective
 MS. REC CEO
 M: Meta
o Statistical analysis/formula of multiply analysis
o Results are written in #’s
o Large groups
o Statistical power
■ Key words
 Database, CINAHL, PubMed, Medline, etc.
 Pulling/Combining multiple articles/research projects together
 Summary
 Analysis
 Multiple studies included
 S: Systematic Review
o Systematic review of multiple articles pulled together
o Summarize findings/Literature review
■ Key words
 Database, CINAHL, PubMed, Medline, etc.
 Pulling/Combining multiple articles/research projects together
 Summary
 Analysis
 Multiple studies included
 R: RCT (Randomized Control Trials)
o Double blinded
o Randomly assigned subjects
■ Key words
 EXPERIMENTAL studies
 Random assign
 Study interventions
 Trials
 Will have a Placebo & Control groups
 E: Experimental
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o Random
o Not double blinded
■ Key words
 EXPERIMENTAL studies
 Random assign
 Study interventions
 Trials
 Will have a Placebo & Control groups
 C: Cohort
o Longitudinal- follows same group of people over a long period of time with same
characteristics
o Prospective- looks forward
o Retrospective- looks backwards
o No intervention done (but there may be an exposed and a not exposed group)
o Can determine risk of developing a disease
■ Key words
 ALL OBSERVATIONAL (no experiments done, just looking and
observing)
 Retrospective
 C: Case-Control
o Retrospective- looks backwards
■ Ex: at outbreak of the flu 2 years ago? Why did it happen? How?
■ Observe only. Want to know why the outcome happened
■ Analyze the outcome
 Key words
o ALL OBSERVATIONAL (no experiments done, just
looking and observing)
o Retrospective
 C: Cross-Sectional survey
o Analyze/compare differences and similarities of a population (group) at one point
in time
■ Key words
 ALL OBSERVATIONAL (no experiments done, just looking and
observing)
 Retrospective

 C: Case Series/Report
o Retrospective- looks back at 1 point
■ Key words
 ALL OBSERVATIONAL (no experiments done, just looking and
observing)
 Retrospective
 E: Editorial
o Essay
o Journal editorial
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■ Key words
 OPINION of an expert
 Seeking opinion
 Editorial
 O: Opinion
o MD opinion
o Essay on concern
o Personal experience
■ Key words
 OPINION of an expert
 Seeking opinion
 Editorial

1. First find the STRONGEST answer within the 3 examples they give you. So, look for key
words➔ meta-analysis, systematic reviews, database, Medline, CINAHL, or RCT,
experimental groups…etc.
2. Find the WEAKEST evidence, look for key words such as ➔ Expert opinion, editorial,
etc.
3. Left over goes into the middle.

What is a 3rd party payer?

 3rd party payer is the insurance company. The patient is the 1st party and the health care
provider is the 2nd party

Occurrence-based policy:
 Malpractice claims against the NP are covered in the future as long as the alleged
incident occurred during the time period when the policy was active

Claims-based policy:
 Malpractice claims against the NP are covered only if the NP has an active policy with
the same malpractice insurance company. When the NP retires and discontinues the
insurance, he/she will need to buy tail coverage which can protect them in the future

Where do RN’s and NP’s get legal authority to practice?

 From the State Legislature (who enacts the State’s Nurse Practice Act)

State Board of Nursing (SBON):

 Has legal authority to license, monitor, or discipline nurses who practice in their State

Consultative Relationship:
 Informal process involves two or more providers that exchange information about a
patient occasionally
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IRB Committee Members:

 Staff members or consultants affiliated with the institution. Possible members are:
experienced RNs/NPs, staff physician’s and staff pharmacist

Sensitivity:
 The proportion of persons with the disease who are correctly identified by a screening
test as having the disease
 Positive

Specificity:
 The proportion of persons without the disease who are correctly identified by a screening
test as not having the disease
 Negative

Independent variable:
 Characteristic or variable being observed or measured

Dependent variable:
 Outcome that is caused by the influence of the independent variable

Mean:
 Same as the average
 Add all the scores together and divide by the total number

Median:
 Number in the middle when the scores are arranged from the lowest to the highest

Mode:
 The most frequently occurring value

Normal curve:
 A bell-shaped curve

Pharmacodynamics:
 Effects of drugs and the mechanism of their action

Pharmacokinetics:
 The process by which a drug is absorbed, distributed, metabolized, and eliminated by the
body
o Half-life (t ½):
■ Amount of time it take for the blood level/concentration of a drug to
decrease by half (50%)
o AUC (area under the curve):
■ Amount of the drug that is in the body after the administration of a dose
o Maximum concentration:
■ The highest concentration of a drug after a dose
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o Trough (minimum concentration):

■ Lowest concentration of a drug after a dose

First Pass Metabolism:

 Applies only to oral drugs
 All oral drugs undergo the first pass metabolism either in the GI tract and/or the liver
o Affects the bioavailability of the drug and can reduce the concentration when it
reached its site of action

Legal Documents:
Advanced Directive:
 A legal document with written instruction listing the patients desire for
treatment/non-treatment

Living Will:
 A type of advanced health directive containing instructions (from the patient) on the
type of medical care that he/she desires in case he/she is unable to communicate their
wishes at a future time (avoid mechanical ventilation/tube feedings/DNR, etc.)

Durable Power of Attorney of Health (health care proxy):

 A legal document where the patient appoints another person to make medical
decisions for him/her in the event that he/she becomes severely incapacitated
(comatose, dementia). Can be a friend or spouse

Guardian Ad Litem:
 Latin “guardian at law”. Person (social worker, lawyer, etc.) appointed by the court
who has the legal duty to represent the best interest of a minor child (called a ward).
Someone who is taken away from their parents

Informed consent must contain:

*The patient must not be under the influence of drugs
1. Patients’ diagnosis (if known)
2. The nature and purpose of the treatment/procedure
3. The risk and benefits of the proposed treatment/procedure
4. Other treatment alternatives (with the risk vs. benefits of the alternative
treatment/procedure explained)
5. The risk and benefits of not undergoing the treatment/procedure

Motivational Interviewing:
 Useful for addictions, alcohol abuse, and chronic illness, life style changes (obese,
diabetics, asthma, safe sex, etc.)
 A tool used for unhealthy behavior changes
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Beneficence (benefit):
 Obligation to help the patient. Acting in the patient’s best interest. Core principle in
patient advocacy

Non-maleficence:
 Obligation to avoid harm. Protecting a patient from harm. Ex: having ongoing education
to prevent pt. harm

Utilitarianism:
 Outcome of the action is what matters with utilitarianism. Means to use a resource for the
benefit of most. Ex: WIC program

Justice:
 The lack of bias. Right to fair and equitable treatment. The fair and equitable distribution
of societal resources

Dignity:
 Respect for human dignity. A person’s religious, personal, and cultural beliefs can
influence what a person consider dignified treatment

Fidelity:
 Keeping one’s promise. Maintaining trust in a relationship. Ex: not lying to patients

Confidentiality:
 Obligation to protect the patient’s identity, personal information, test results, and medical
records

Paternalism:
 Making decisions for a patient (or for others) because you “believe” that it is for their
best interest

Accountability:
 Health care providers are responsible for their own choices and actions and do not
blame others for their mistakes

Veracity:
 Telling the truth and presenting information honestly

Leininger’s Cultural Care Diversity and Universality Model/Theory:

 Defines “culture” as “the specific pattern of behavior that distinguishes any society from
others and gives meaning to human expressions of care”
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Giger and Davidhizar’s Model of Transcultural Nursing:

Cultural Sensitivity
 Respect for diversity, and acting in a manner that is considered respectful by the other
such as use of distance, negotiating, choice of words

Cycle of Change/Change Theory:

Pre-contemplation:
o Does not intend to change behavior. In denial
Contemplation:
o Becoming more aware that condition is affecting health, but still sitting on the
fence. Not committed to quit yet
Preparation:
o Makes active plant to stop behavior. May research current behavior on the
internet, ask questions etc.
Action:
o Throws away whatever is causing the bad behavior. Tells family and friend that
they are trying to stop bad behavior
Maintenance:
o Attend (ex: AA) meetings. Contacts mentor
Relapse:
o Goes back to old hangouts where he/she used to do bad habit

Therapeutic Communication:
 Communication is not only verbal but involves non-verbal cues, emotions and body
language
 Ask open-ended question
 Use receptive body language
 Acknowledge a patient concerns and fears. Do not REASSSURE patients
 Maintain good eye contact, face the patient, lean slightly towards the patient

 Know what Medicare Part A covers

o Inpatient/hospitalization costs
o Pays for some disabilities such as end stage renal disease
o Hospice skilled nursing facility
o Home health care
o Semi-private rooms, meals, PT, OT, speech therapy, medication, supplies, in
facility, ambulance, transportation for emergent cases, dietary counseling, social
worker

 Be familiar with hospice and palliative care services and how to qualify
o Physician must write an order for hospice care
o Physician certifies that patient has a life expectancy of less than 6 months
o Patient gives consent to be admitted to a hospice program
o The patient agrees not to use life-sustaining equipment if a life-threatening even
occurs during the hospice time period
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o Depending on the insurance benefits, patients who need physical, occupations, or

speech therapy for palliative purposes are allowed to continue in hospice

 Telemedicine:
o Practice of medicine using technology to deliver health care at a distance,
increasing a patients access to health care.

 Endemic:
o Refers to a baseline level of a particular disease in a population
 Epidemic:
o Refers to the rapid increases of a disease in a population that involves a large
number of people
 Pandemic:
o An epidemic occurring over a very wide area (several counties or continents)