Liek Study Guide for NP Board, Study notes of Nursing

Download Liek Study Guide for NP Board and more Study notes Nursing in PDF only on Docsity! LEIK EXAM TIPS Health Screening and Health Promotion US Health Statistics/Mortality Statistics Leading cause of death (all ages/genders): 1. Heart disease (or diseases of the heart) 2. Cancer (or malignant neoplasms) 3. Chronic lower respiratory diseases (i.e., chronic obstructive pulmonary disease [COPD]) Leading Cause of Cancer Death 1. Lung Cancer for both men and woman 2. Men – prostate & Woman- Breast 3. Colorectal Cancer for both men and woman Leading Cause of Death in Adolescents (^ in males than females) 1. Accidents /Unintentional Injuries 2. Suicide 3. Homicide Leading Cause of Death by Age Group  Birth to 12 months:  Congenital malformations (20.3%)  Ages 1 to 44 years:  Unintentional injuries  Ages 45 to 64 years:  Cancer (30.9%)  Ages 65 and older:  Heart disease (25.6%) Average Life Expectancy: 78.8 years of life Cancer Statistics Most Common Cancer: skin cancer Most Common type of skin Cancer: Basal Cell Carcinoma and Melanoma causes the majority of skin cancer related deaths. Most Common Cancer by Gender  Men – Prostate cancer (there are more cases of prostate cancer, however lung cancer is still the highest mortality cancer associated to males).  Females- Breast Cancer (there are more cases of breast cancer, however lung cancer is still the highest mortality cancer associated to females). Most Common Cancer among all children: Acute Lymphoblastic Leukemia (34% of all cancers in children). Sensitivity vs. Specificity  Sensitivity: is a good way of detecting those people who have the disease (i.e. true positive).  Specificity: is a good way of detecting those people without the disease (i.e. true negative). Top Three Cancers in Children  Leukemia (34%)  Brain and nervous system tumors (27%)  Neuroblastoma (7%) Health Promotion Aspirin Use to prevent Cardiovascular Disease or Colorectal Cancer  Begin at age 50-59 with =/> 10 % risk for cardiovascular disease (ASCVD score) Breast Cancer  Risk factors o age 50 or greater, o previous hx of breast CA, o two or more first * relatives o nulliparity, early menarche, late menopause (longer exposure to estrogen) o Obesity (adipose cells can synthesize small amounts of estrogen)  Baseline mammogram starts at 50 years of age  Repeat every 2 years from ages 50-74 years of age NOTE: Does NOT apply to those individuals with known genetic mutations (BRCA1 or 2), familial breast cancer history, history of chest radiation at a young age or previously diagnosed with high risk breast lesions, who may benefit from starting screenings at age 40. So, essentially if at high risk start screenings at age 40-49. Cervical Cancer  Risk factors o Multiple sexual partners o Younger age onset of sex o Immunosuppressed and/ or smoking individuals. Age Group Recommendations for Pap/Liquid Cytology Age 20 years or younger Do not screen (even if sexually active with multiple partners). rare before age 21 Age 21 to 65 years Baseline at age 21 years. Screen every 3 years. Age 30 to 65 years Another option starting at age 30 years is to screen with combination of cytology plus human papillomavirus (HPV) testing every 5 years. Had hysterectomy with removal of cervix If hysterectomy with cervical removal was not due to cervical intraepithelial neoplasia (CIN grade 2) or cervical cancer, then can stop screening. Women older than 65 years who had adequate prior screening Do not screen if history of adequate prior screening and is otherwise not at high risk for cervical cancer. General Recap of Screening Recommendations Baseline Notes Abdominal aortic aneurysm (AAA; June 2014) Breast cancer (January 2016) Blood pressure in adults (hypertension; October 2015) Colon/colorectal cancer (June 2016) Depression Depression (adults; January 2016) Diabetes mellitus (DM) type 2 (October 2015) Latent tuberculosis (September 2016) Lung cancer (December 2013) Obesity Sexually transmitted infections (STIs; September 2014) Skin cancer(July 2016) Osteoporosis (being updated) Ovarian cancer (September 2012) Pancreatic cancer (February 2014) Men at age 65 to 75 years who have smoked Start at age 50 years Age 75 years or older” Breast self-exam (BSE) Start at age 18 years or older Start at age 50 years continue until age 75 years Age 76 to 85 years Age older than 85 years Adolescents (12-18 years) General adult population Age 40 to 70 years if ‘overweight or obese Asymptomatic adults Aged 55 to 80 years with history of smoking Start at age 6 to 18 years Start at the onset of sexual activity Insufficient evidence Start at age 65 years or older Against routine screening Against routine screening One-time screening with ultrasonography in men ages 65 to 75 years who have smoked; individualize for men who never smoked Mammogram every 2 years (biennial) until age 74 years Stop routine screening. Individualize” Against teaching BSE (Grade D recommendation) Recommends obtaining measurements outside of clinical setting for diagnostic confirmation before starting treatment High-sensitivity fetal occult blood test (FOBT; every year), or sigmoidoscopy (every 5 years), or colonoscopy (every 10 years) Individualize" Stop routine screening Start screening for major depressive disorder starting at age 12 to 18 years Include pregnant and postpartum women; use Beck Depression Inventory Applies to adults in primary care settings who are not “high risk”; DM patients with risk factors (certain ethnicities, PCOS, GDM, etc.) can undergo screening at younger age Screen asymptomatic adults who are at increased risk for infection Low-dose computed tomography (LDCT) if currently smokes with 30-pack-year history or quit in the previous 15 years Offer or refer for intensive behavioral interventions High-intensity behavioral counseling for sexually active adolescents and adults who are at high risk for STIs Routine screening is not recommended; individualize recommendation May start earlier if a younger woman has a fracture risk equal or greater than that of a 65-year-old White woman (i.e., chronic steroids) Do not screen for ovarian cancer except high risk (as of September 2016) Vaccination Facts Hepatitis B Vaccine  Total of 3 doses with one given at birth and 4 weeks given between 1st and 2nd dose.  If patient only one dose of hep B vaccine? o Do not restart the series, just give the second dose. Then given 3rd when time permits. Influenza Vaccination  6 months is the youngest age at which it can be given.  Most flu vaccinations are manufactures using egg-based technology. o Note: only 1.3% of children and only 0.02 % of adults have egg allergies.  Use caution with pt’s with previous reactions, history of Guillain-Barre syndrome within 6 weeks prior to previous immunization.  Live vaccine contraindications o Pregnancy o Chronic disease (i.e. COPD, Renal failure, DM, and immunosuppression). o In children on aspirin therapy ages 2-64 years of age. Tetanus Vaccines (Tdap and/ or Td)  Given every 10 years with boosters (i.e. contaminated wounds) every 5 years.  Age Implications o Infancy and younger than 7 years of age : use DTap form. o 7 years of age and older: only use Td or Tdap forms of the vaccine o All forms are given IM  Tdap can be used as a booster and substitute for Td (but only once in a lifetime) in adolescent and adults starting at 11-12 years of age.  What do you do for someone with a tetanus prone wound that has no tetanus history? o Give Td/Tdap vaccine and the tetanus immunoglobin (TIG) injection ASAP.  High risk wounds for Tetanus exposure o Puncture wounds o Wounds with devitalized tissue o Soil contaminated wounds o Crush injuries o Other injuries that are high risk for tetanus infection.  Use in caution with hx of Guillian-Barre Syndrome within 6 weeks of previous dose as well as pertussis component in individuals with progressive or unstable neurological disorder and or uncontrolled seizures. Pneumococcal Vaccinations  Pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax (50% effective): 65 years of age or older.  Pneumococcal conjugate vaccine (PCV13 or Prevnar) (85% effective) o All children less than 5 years of age o Those who are at high risk for pneumococcal disease  Chronic Disease (alcoholism, DM, CSF leaks, asthma, chronic hepatitis).  Anatomical or functional asplenia (including sickle cell disease)  Immunocompromised or on medications that are immune-compromising.  Malignancy or cancers of the blood.  Renal Disorders  History of organ or bone marrow transplant.  65 years or older – CDC recommends giving PCV 13 first (if they never had PPSV23) then 12 months later give PPSV23 (better immunologic response is seen with this order)  In Adults less than 65 years of age who were previously vaccinated with Pneuovax 23 a booster should be given every 5 years after the initial dose. Shingles Vaccination  Risk factors for shingles o Older age (60 or >) o Immunocompromised – HIV, steroids, chemotherapy o Leukemia or lymphoma  Zoster Vaccine (Zostavax) is a LIVE vaccination.  Give at age 60 with a one time-SC even with a past history of shingles or chicken pox.  Certain anti-viral medications (acyclovir, famciclovir, valacylovir decrease the effectiveness if taken within 24 hours prior and 14 days after vaccination.  Can cause an exacerbation of asthma and polymyalgia rhematica (PMR)  Youngest age Zostavax can be given is 50 years of age.  Shingles is contagious until the lesions are dry and crusted (follow contact precautions)  NOTE: Shingles vaccine has 14 more times VZV then the varicella vaccine (Varivax) Varicella Vaccination  Varivax is a LIVE vaccine  1st Dose: given at 12-15 months (no younger) and ADVISE woman not to get pregnant for 1 month after getting vaccination.  Reactions: Mild rash or several small chickenpox rashes can occur after vaccination (contagious, avoid immunocompromised people).  DO NOT administer to someone born in the United States before 1980 Immunizations for Health Care Workers  Td or Tdap: Give one-time dose of Tdap for all health care personnel who have not received the Tdap when due for a tetanus booster. Continue giving Td boosters every 10 years for a lifetime.  MMR: Proof of immunity is necessary (born before 1957, laboratory confirmation such as positive titers). If not vaccinated for MMR, two doses are needed (at least 28 days apart).  Varicella: Proof of immunity is necessary (positive varicella titer, documentation of two doses of varicella vaccine or diagnosis of varicella by physician/health care provider).  Hepatitis B: If incomplete hepatitis B series (fewer than three doses), complete the series (do not restart). If job involves blood or body fluids, obtain anti-HBsserological testing 1 to 2 months after dose 3. If anti-HBs is less than 10 mIU/mL, three additional doses should be administered on the regular hepatitis B schedule followed by anti-HBs testing in 1 to 2 months. Diphtheria  Clinical Manifestations: o Sore Throat o Hoarseness with dysphagia o Low grade fever o Markedly swollen neck (Bull neck) o Posterior pharynx, tonsils, uvula, and soft palate are coated with gray-to yellow colored pseudomembrane  Management: o Contact Isolation: VERY contagious. o Refer to ED Head, Near, Eyes, Nose, and Throat Review (EXAM TIPS ONLY) Seasonal Allergic Rhinitis  Topical steroid nasal spray (Flonase is the 1st line defense). Uticaria  New onset is treated with Benadryl (sedating and last a few hours) or Zyrtec (last 24 hours) Mononucleosis (Acute or Reactivated)  Clinical Manifestations o Generalized maculopapular rash o Enlarged tonsils o Cryptic Exudate (white or darker color) o Sore throat o Enlarged Cervical nodes that are tender to touch. Otitis Externa  Common Pathogen – Psudomonas  Treatment for Otitis external is Cortisporin Otic Drops. Ruptured Spleen  Avoid contact sport for 4 weeks until US show resolution. Beta Blocker eye drops (Timolol)  Used to decrease intraocular pressure  Has the same contraindications as PO beta blockers. Cholesteatoma  Peri-orbital sinusitis complication that results in a cauliflower like growth accompanied by foul-smelling ear discharge.  Clinical Manifestations o No visualization of TM or ossicles  Treatment: Abx, surgical debridement and refer to EENT Penicillin allergic patients  Use Macrolides and quinolones that have gram + coverage (usually 4th generation abx)  Avoid Cephalosporin’s if patient has had a class I reaction or anaphylaxis to PCN. Learn to recognize Eye descriptions Chalazion:  Chronic inflammation of the melbomian gland (specialized sweat gland) of the eye lid  Painless and can resolves spontaneously in 2-8 weeks and/ or enlarge over time.  Often times pt’s c/o of gradual onset of small superficial nodule on the upper eyelid that feels like “bread” Pinguecula:  Yellowish to white small white growth of the bulbar conjunctiva located next to the cornea  Due to UV light damage to collagen. Pteygium:  Yellowish triangular “WEB SHAPED” thickening of the conjunctiva that extends to the CORNEA on the nasal side.  Can be red and inflamed at times and Pt’s often c/o of foreign body sensation on the eye. Treatment for BOTH pinguecula and Pteygium  If inflamed – use weak steroid eye drops during exacerbations  Recommend good quality sunglasses  Remove surgically if encroaches cornea and affects vision. Cerumenosis  Impacted wax blocking auditory canal  Txt: OTC is carbonate peroxide (similar to hydrogen peroxide) Vision  What someone sees at 20/40 vision means that they can see at 20 feet can see what the normal person at 40 ft can see. Herpes Keratitis  Two Types o Herpes Simplex Keratitis – infection due to herpes simplex virus. (self inoculation “cold sores: or herpes whitlow) o Herpes Zoster Ophthalmicus- acute eruption of crusty rash that follows the ophthalmic branch (CN V1) of the trigeminal nerve on only one side of the forehead, eyelids, and/ or tip of nose. (ED REFFERRAL)  Clinical Manifestations: o Severe onset of eye pain o Photophobia o Tearing o Blurred vision in one eye  Diagnosed: Fluorescein dye with black lamp in a dark room. (fern like lines in the corneal surface).  Management: o Shingles form send to ED ASAP. Corneal Abrasions or Keratitis  Use fluorescein strips to diagnosis/check Papilledema- swollen optic nerve RT to ^ ICP secondary to bleeding, tumor & etc. Hypertensive Retinopathy  Copper and silver wire arterioles (caused by arteriosclerosis)  AV nicking (when arteriosclerotic arteriole crosses the retinal vein and thus causes and indentation. Retinal hemorrhages occur as well. Diabetic Retinopathy  Micro-aneurysms are caused by neovascularization (new fragile arteries in the retina that rupture and bleed).  Cotton wool spots- look like fluffy yellow-white patches on the retina. Cataracts  Opacity of the lens of the eye (central or on the sides (cortical)).  Difficulty with glare (with headlights when driving at night or sunlight) , halos around lights, blurred vision. Koplik’s Spots  Cluster of small red papules with white centers inside the checks by the lower molars that is usually indicative of Measles. Hairy Leukopenia  Elongated papilla of the tongue that is usually indicative of HIV infection that is caused by the Epstein-Barr Virus. Cheilosis  Painful skin fissure at the corners of the mouth due to excessive moisture (most common in elderly with dentures).  Secondary infections with yeast of bacteria can occur, but also multiple etiologies such as over salvation, poorly fitting dentures, nutritional deficiencies, lupus, autoimmune disease, irritant dermatitis, squamous cell carcinoma, and pacifier us in children.  TXT- o treat underlying cause (i.e. yeast, bacteria, use of pacifiers, or dentures no fitting correctly). o Once underlying cause is treated use barrier creams with zinc or petroleum jelly applied at night b/c there is a high rate of reoccurrence. Measles- (Rubeola)  Viral infection also called Rubeola  Description: Koplik’s spots are small, white round spots on red base on the buccal mucosa by the rear molars.  Management: analgesics and preventative with MMR vaccine Scabies  Description: very pruritic, even more at night, Serpiginous rash between the finger/toes, waist, axilla, and /or penis. Scarlet Fever  Description: sandpaper rash with sore throat (strep throat) Tinea Versicolor  Description: hypo-pigmented round to oval macular rash that is usually on the upper back/shoulders (not itchy) Pityriasis Rosea  Description: “Christmas tree” pattern rash that is usually seen on cleavage lines.  Herald patch is also seen and this appears initially. Molluscum Contagiosum  Description: smooth papules 1 mm size that are usually dome-shaped with central umbilication with a white plug. Erythema Migrans (Lyme Disease)  Description: (bulls eye target lesions) Red like target lesions that grow in size with some degree of central clearing (early stages of Lyme Disease)  Common locations: belt line, axillary area, behind the knees, and in the groin. Meningococcemia  Clinical Manifestations o Description: purple colored to dark red painful lesions all over the body o high fever o HE o LOC changes  Treatment: Give Rifampin prophylaxis for close contacts.  Management: Aerosol Droplet precautions Rocky Mountain Spotted Fever  Clinical Manifestations o Description: red spot like rashes that first break out on the hand/palm/wrist and on the feet/sole/ankles accompanied with o Acute sudden onset high fever, severe headache, and myalgia  TXT: 1st line is Doxy Skin and Integumentary System Exam TIPS only Differentiate between contact dermatitis and atopic dermatitis Atopic Dermatitis: (Eczema)  Extremely pruritus rash located on hands, flexural folds, neck and exacerbated by stress.  Clinical Manifestations o Starts as multiple vesicles that rupture, leaving painful, bright red, weepy lesions that eventually become lickenfield from chronic itching.  NOTE: Familial history of atopy is usually present. Contact Dermatitis:  Inflammatory skin reaction due to external irritants.  Description o Can be single lesion or generalized rash. o Can follow a pattern or have asymmetric distribution. Scabies  Rash that is very pruritic at night and located on the inter-digital webs and/ or penis are scabies UNTIL proven otherwise  Treat close contacts  Wash linens and clothes in hot water. Human dog/ cat Bite  Preferred txt is Augmentin Hydranitis Suppurativa  Bacterial infection of the sebaceous glands in the axilla or groin by S. Aureous.  Usually becomes chronic.  TXT: Drainage and ABX Psoriasis  Inherited skin disorder that produces fine , silvery white scales (also called “fine scales”) accompanied with pitted fingernails and toe nails.  Clinical Manifestations:  Koebner phenomenon  Auspitz Sign  TXT: Steroids, Psoralens (tar-derived topical) and antimetabolite (methotrexate). RMSF  Petechial rash that starts on hands and feet and then spreads and appears on the 3 day after onset of  Clinical Manifestations o high fever o Severe headache o Myalgia, o Red eyes o N/V o Arthralgia  TXT: Doxy Meningococcemia  Clinical Manifestations: Sudden onset of sore throat, cough, fever, HE, stiff neck, photophobia, change in LOC, and a petechial to hemorrhagic rash (pink to purple) in the axillae, flanks, wrists, and ankles  High risk for pt’s living in Dorms  Management: Droplet precautions  TXT: Rifampin prophylaxis for those in close contacts Erythema Migrans (Lyme Disease)  Bull’s eye rash that usually appears within 7-14 days after deer tick bit. Rash it hot to touch, and rough texture.  TXT: doxy Rosacea  Chronic inflammatory skin disorder that can produce acne like papules and pustules around the nose, mouth, and chin.  Usually have fair skin color at baseline.  TXT: topical Metronidazole gel Acne  Mild acne is only treated with topicals. Pityriassis Rosea  Herald’s Patch Post-Herpectic Neuralgia  Prophylaxis is TCA’s Differentiate erysipelas vs. other cellulitis Erysipelas  Cellulitis only involving the upper dermis and superficial lymphatic’s that is usually caused by A. Streptococcus.  CLUE: Any cellulitis questions often involve pt’s being barefoot. Cardiovascular EXAM tips  Advise all HTN Pt’s to DECREASE NA+ intake.  How to decrease triglycerides  Major bleeding suspected check INR, PTT, and PT b/c INR can be normal.  Coumadin is category X New York Heart Association Class II Heart Disease (Functional Capacity Ratings)  Ordinary physical activity results in fatigue, exertional dyspnea. Risk Factors for DVT’s o Birth control, pregnancy, bone fractures , trauma, surgery, and malignancy. Raynaud’s Phenomenon  Reversible vasospasm of the peripheral arterioles on the fingers and toes with unknown cause, but strongly associated with autoimmune disorders (especially scleroderma).  Description: Color ranges from white (palor), blue (cyanosis), to red (reperfusion).  TXT- CCB’s Bacterial Endocarditis  Bacteria Pathogen- gram (+) viridans streptococcus and S. Aureus  Clinical Manifestations: o fever, chills, malaise, o subunal hemorrhages (splinter hemorrhages on nail bed) o Janeway lesions- red macules palms/soles that NOT Painful. o Osler’s nodes- painful violaceous nodes found mostly on the pads of the fingers, toes, thenar eminence. o Some pt’s have heart murmur. Metabolic Syndrome  Metabolic syndrome is a cluster of symptoms. o Abdominal obesity (> 40 inches in men and > 35 in females). o HTN o HLD o Fasting glucose >100 o ^ triglycerides >150 o Decreased HDL < 40 Nonalcoholic Fatty Liver Disease (NAFLD) – usually asymptomatic  Caused by triglyceride fat deposits in the hepatocytes of the liver.  Risk Factors: obesity, DM, metabolic syndrome, HTN, drug induced. Overweight  BMI of 27  1st line txt is lifestyle modifications with diet. Pulmonary System Exam Tips COPD  1st line txt is either SABA or short acting anticholinergics (Atrovent). If poor response with 1 single agents add second agent, so if on SABA add short acting anticholinergic (Ipratropium (Atrovent).  If short acting meds are not controlling symptoms next step is to start pt on a LABA or a LAMA (salmeterol or formoterol), but can continue with SABA as needed.  Only txt to prolong life – supplemental oxygen.  COPD smoker with PNA- cause is most likely Haemophilus influenza, so when you pick an antibiotic choose one that has coverage for both Haemophilus influenza and Streptococcus Pneumoniae.  Do NOT use LABA for rescue inhaler. Rescue Inhalers- Short acting B2 Agonist (Albuterol and Xopenex. Bacterial Pneumonia (Community Acquired Pneumonia)  1st cause is Streptococcus Pneumoniae & 2nd is Haemophilus influenzae  Clinical Manifestations  Acute onset with high fever, chills, productive cough (mucous green to rust color), pleuritic chest pain with and/ or without cough.  Lung Sounds- crackles, decreased breath sounds, dull  Diagnostic  CXR- lobar infiltrates. Outpatient CAP- based on S/S and CXR, do not order phlegm for C&S or CBC. Atypical Pneumonia (Walking Pneumonia)  Mycoplasma is most common and Chlamydia  Clinical Manifestations o Gradual onset, low grade fever, HE, sore throat, cough, and sometimes rash o Lung sounds- wheezing  Diagnostics o CXR- interstitial to patchy infiltrates  Usually seen in young adults. o Depending on the stage of the disease and hydration status CXR may result in normal during the early stages of bacterial PNA (lobar PNA). Pertussis / Whopping cough  Coughing illness that last at LEAST 14 days and up to months that is usually caused by Bordetella Pertussis bacteria.  Clinical Manifestations  Excessive barking cough, inspiratory whooping without apparent cause.  Has 3 stages  TXT: Macrolides (Azithromycin), antitussives, mucolytic, rest, hydration , and small frequent meals.  NOTE: Suspect pertussis in a “healthy adult with no fever who has been coughing for more than 2-3 weeks, especially if they were treated with a abx that was not a macrolide and is getting worse. However, r/o PNA 1st. Acute Bronchitis  TXT- NO abx  Treatment is symptomatic based, so increase fluids, rest, smoking cessation, dextromethorphan, Tessalon perles, inhalers, and possible steroid Medrol dose pack. TB  PPD > 10 suggestive of TB, but if there is 9.5 and c/ o of symptoms this is suggestive of TB  Never txt with fewer than 2-3 drugs.  Pt’s with HIV with CD4 count < 500 or pt’s who are taking tumor necrosis factor antagonists or biologics are at ^ risk for TB.  Can use TB skin test during pregnancy.  Younger children ^ likelihood then older adults to develop life threatening TB. Peak Expiratory Flow Rate (PEFR or PEF)  Measures effectiveness of treatment, worsening of symptoms.  Based on ht, age, gender (HAG) High dose inhaled corticosteroids  Can cause osteoporosis, mild growth retardation in children, glaucoma, cataracts, immune suppression, hypothalamic-pituitary adrenal suppression. Asthmatics  1st line txt for SEVERE asthmatic exacerbation is adrenaline injection  Must always have a rescue inhaler (short acting B2 agonist) Long term Corticosteroids  Can increase risk for PNA Mucolytic  best option is hydration b/c it thins secretions. Lung Cancer  Can present as recurrent PNA due to mass blocking bronchioles. Asthma pg. 218……………… Endocrine Exam Tips Subclinical Hypothyroidism  TSH is elevated and there is a normal T4 level.  Do not treat, but recheck the TSH in 6 months. Acute Pancreatitis: Cullen’s Sign (blue discoloration around umbilicus) & Grey-Turner’s Sign (blue discoloration on the flanks). Also may have ileus and show signs of shock. Clostridium Difficile Colitis: severe watery diarrhea from 10-15 stools a day. Usually appears 5- 10 days after the start of antibiotics. Especially common with clindamycin, fluoroquinolones, cephalosporin, and PCN”s. Colon Cancer  Gradual onset with very vague symptoms,  Clinical Manifestations: o Iron-deficiency anemia, change in bowel habits, bloody stools, heme-positive stools, dark-tarry stool, and mass on abdominal palpation. Crohn’s disease and Ulcerative Colitis. Crohn’s Disease:  Form of inflammatory bowel disease that affects any part of the GI tract from mouth (canker sores are common) small –large intestine, rectum, and anus. If ileum is involved there is watery diarrhea without blood of mucus.  Fistula formation and anal disease only occurs with CD and NOT with UC. Also may palpate a tender palpable mass.  Increased risk for colon CA, lymphoma, and toxic megacolon (especially in pt’s treated with Azathioprine. McBurney’s Point:  The name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus (navel). This point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum.  Positive in Appendicitis Psoas/Iliopsoas (supine position)  RLQ abdominal pain that occurs when the hips are flexed at a 90* angle then have the patient push against the examiners hand to try and straighten the leg.  Positive in Appendicitis Obturator Sign  Positive if inward rotation of the hip causes RLQ abdominal pain. Rotate right hip through full range of motion. Positive sign is pain with the movement or flexion of the hip.  Positive in Appendicitis Rovsing’s Sign (supine position)  Deep palpation of the left lower quadrant of the abdomen that results in pain to the RLQ.  (+) in Appendicitis Markle Test (Heel Jar)  Instruct patient to raise heels and then drop them suddenly. An alternative is to ask the patient to jump in place. Positive if pain is elicited or if patient refuses to perform because of pain. Involuntary Guarding : With abdominal palpation, the abdominal muscles reflexively become tense or board-like. Barrett’s Esophagus  Precancer to esophageal cancer  Diagnosed by upper endoscopy with biopsy. Lifestyle Modifications  Avoid mints and caffeine? – WHY???? Cullen’s Sign  Edema and bruising of the subcutaneous tissue around the umbilicus Nervous System LEIK EXAM TIPS Danger Signs with headaches  Abrupt onset of severe headache “Thunderclap headache”  “Worst headache of my life”  First onset of headache at age 50  Sudden onset of HE after coughing, exertion, straining, or sex (i.e. exertional headache)  Sudden change in LOC  Focal neurological signs (i.e. unequal pupil size).  HE with papilledema (i.e. can be secondary to “ Worst Case List” Below o Subarachnoid hemorrhage or acute subdural hemorrhage. o Leaking aneurysm o Bacterial Meningitis o Increased ICP o Brain Abscess o Brain Tumor Acute Bacterial Meningitis  Clinical Manifestations o Acute onset of high fever o Severe headache o Stiff neck o Meningismus – symptoms related to inflammation of the meninges. o Class purple colored petechial rash o Nausea/vomiting o Photophobia o Can lead to lethargy, confusion, and / or coma • NOTE: Bacterial Meningitis is REPORTABLE Temporal Arteritis (Giant cell Arteritis)  Clinical Manifestations o Acute onset of headache located on one temple on an older adult o Affected temple is indurated, reddened, and cord like that is tender to touch. o Scalp tenderness o Abrupt onset of visual disturbances and/ or transient blindness of the affected eye (amaurosis fogax). o Jaw pain or jaw claudication  Labs 6. Abducens Nerve (VI 7. Facial Nerve (VII) 8. Vestibulocochlear Nerve (VIII) 9. Glossopharyngeal Nerve (IX) 10. Vagus Nerve (X) 11. Spinal Accessory Nerve (XI) 12. Hypoglossal Nerve (XII) Herpes Zoster Infection (Shingles)  Affects cranial nerve V, the ophthalmic branch which can result in corneal blindness.  NOTE: if there is a rash at tip of nose and the temple area, you must r/o shingles infection of the trigeminal nerve. Acute Bacterial Meningitis  An acute bacterial infection of the leptomeninges that cover the brain and spinal cord.  Pathogens: Streptococcus Pneumoniae, Neisseria meningitides, Haemophilus influenza (the later two being of a gram (-) origin.  Clinical Manifestations o Acute onset of high fever o Severe headaches o Stiff neck (nuchal rigidity) o Rapid changes in mental status and LOC : Confusion, lethargy, and/ or stupor. o Photophobia o Nausea and/ or Vomiting  Bacterial meningitis is a reportable disease to the local health department.  Labs o LP- CSF contains large number of WBC’s, elevated protein, and low glucose levels. (usually CSF is cloudy, but a definitive diagnosis is made from bacteria that is isolated from the CSF). o Elevated opening pressure (need CT or MRI) o CBC with differential, CMP, Coagulation factors, platlets, and blood cultures X2  Treatment o Infants: Ampicillin or 3rd generation cephalosporin o Adults: 3rd generation cephalosporin plus chloramphenicol o > 50y/o: Amoxicillin plus 3rd generation cephalosporin. o Prophylaxis: close contacts should be treated with rifampin or ceftriaxone.  Prevention: immunization with pneumococcal vaccination has shown to decrease occurrence.  Complications: o Pt’s who recover usually have permanent neurologic sequelae. o Elderly pt’s have increase mortality rate due to presence of comorbid conditions. Migraine headaches with Aura:  Aura may present as scotomas (blind spots on visual fields) or flashing light that precede a headache.  Increase risk for patients with positive family history and being female (3:1)  Infants- migraines may present as abdominal pain.  Clinical Manifestations: o Gradual onset of bad throbbing headache behind on eye that gradually worsens over several hours. o Photophobia (sensitivity to light) o Phonophobia (sensitivity to noise) o Nausea, and/ or vomiting o Can last anywhere from 2-3 days and may become bilateral if it is not treated.  Treatment o Neurological exam o Rest in quiet, darkened room, with ice pack to head o Nausea: drink ginger ale or chew dry toast. o Avoid heavy fatty meals o Triggers  Avoid precipitating foods  Monosodium glutamate (MSG), Chinese food, chocolate, nitrates/Nitrites (usually found in hot dogs, lunch meat, and / or sausage).  Red wines, beer, and caffeine  Sleep changes, stress, barometric weather changes.  Odor triggers: tobacco smoke, perfumes, and/ or strong odors.  Visual triggers: strobe lights, sunlights, and/ or glares. Treatment of Migraines Abortive: Immitrex (see below) and NSAID’s Sumatriptan (Imitrex)  FIRST: must r/o cardiac disease  Do not use if history of ischemia heart disease (MI, angina), CVA/TIA, uncontrolled HTN or hemiplegic migraine) causes stroke like symptoms to one side) .  S/E: flushing, tingling, chest/neck/sinus/jaw discomfort  Implications: must have first dose supervised (especially if pt’s have risk factors for cardiac disease o Risk factor for Cardiac disease: DM, Obese, males > 40 y/o, high lipids  Risk Factors o Females 50 y/o or greater  Treatment: o Symptoms usually respond well to PO steroids. Trigeminal Neuralgia  Trigeminal nerve has 3 divisions (ophthalmic, V1, Maxillary (V2), and Mandiublar (V3) and is caused by compression of the nerve root by an artery or tumor.  Clinical Manifestations: o unilateral facial pain that follows one of the branches of the trigeminal nerve. o Pain close to the nasal border and checks.  Different Types o Type 1: extreme shock-like facial pain lasting from second to 2 minutes per episode) o Type 2: constant, aching, burning facial pain of low intensitiy,  More common in Woman and peaks in their 60’s.  Treatment: o Anticonvulsants: Carbamazepine (Tegretol) or Phenytoin (Dilantin) o Muscle Relaxants are effective when combined with Anticonvulsants  Oxcarbazepine (Trileptal) used at 1st line defense drug b/c less S/E’s.  Gabapentin and topiramate are also used. o CT/ MRI: scan to r/o tumor or artery pressing on nerve or Multiple sclerosis. Bell’s Palsy  Abrupt onset of unilateral facial paralysis due to dysfunction of the motor branch of the facial nerve (CNVII). Facial paralysis can progress rapidly in 24hours.  Etiology: viral infection, autoimmune process, or pressure form tumor or blood vessel.  CM: o one side of face paralyzed, o difficulty chewing or swallowing on the same side. o Unable to fully close eyelid.  Treatment Plan: o R/ O stroke, TIA, mastoid infections, bone fx, Lyme disease and/ or tumor o Corticoidsteroids at high doses X 10 days then weaning off o Acyclovir if herpes simplex suspected. o Protect cornea from drying and ulceration with eye lubricants in AM and lubricating ointments at HS. Nervous System Exam Tips Carpel Tunnel Syndrome  Cause: by activities that require repetitive wrist/ hand motion usually due to median nerve compression due to swelling of the carpal tunnel  Both hands are affected in 50% of pt’s.  Risk Factors: o hypothyroidism, pregnancy, and/ or obesity, as well as adults who use repetitive wrist/ hand movements in his/her job.  Clinical Manifestations: o Gradual onset (over weeks to months) o Numbness and/ or Tingling (Parathesias) on the thumb, index finger, and middle finger area. o Hand grip is weaker on the affected side. o Chronic/Severe cases involve atrophy of the thenar eminence (group of muscles on the palm of the hand at the base of the thumb (usually a LATE SIGN).  Tinel’s Sign o Tap anterior wrist briskly o Positive Finding: “Pins and needles’ sensation of the median nerve over the hand after lightly percussing the wrist.  Phalen’s Sign o Engage in full flexion of wrist for 60 seconds o Positive Finding: tingling sensation of the median nerve over the hand evoked by passive flexion of the wrist for 1 minute. Cluster Headache  Idiopathic and severe one sided headache that is marked by recurrent episodes of brief “ice prick” (lacerating pain) located behind one eye that is accompanied by tearing and clear rhinitis.  Clinical manifestations: o Abrupt onset may get agitated during headache episode. o Attack happens several times a day. o Resolves spontaneously, but may return in the future in some pt’s/ o More common in adults in 30’s-40’s . o Autominc Symptoms – tearing , clear nasal discharge. o Ptosis (dropping eyelid) .  Treatment o High-dose 02 (don’t give to pt’s with COPD) o Imitrex by IM or intranasal o Prophylaxis: verapamil PO daily  Complication: highest risk of suicide for males. Alternative Headache Remedy  Butterburr and Feverfew ****Headaches: with the exception of muscle tension headaches all headache questions seen on exam are unilateral. *** Muscle Tension Headaches  Emotional/psychic stress in some pt’s cause the muscles of the scalp and neck to become chronically tense. This is a bilateral headache.  Clinical Manifestation o Band-like headache that feels like someone is “squeezing their head” o Pain is dull and constant and often accompanied by tensing of the neck muscles. o May last several days. o Pt c/ o of increased stress in life.  Treatments o NSAID’s (Naproxen (BID) or Motrin 800 mg QID or analgesics (APAP or aspirin) o Narcotics and Butalbital are habit forming and increase risk for rebound HE’s o Combination of OTC analgesics/ aspirin plus caffeine (Anacin, Excedrin). o Stress reduction therapy: yoga, tai chi, regular exercise, gradually reduce and stop caffeine, follow regular sleep patterns, and/ or therapy with counselor. TIPS  Muscle Tension: Causes band like head pain that may last for a few days.  Migraine: presents with throbbing, nausea, photophobia, and phonophobia.  Cluster: only HE accompanied by tearing and nasal congestion, a. severe pain is being one eye/one side of face b. Occurs several times a day. c. Spontaneously resolves d. More common in middle aged males. Trigeminal Neuralgia (Tic douloureux) –  Pain on one side of face/cheek that is precipitated by talking, chewing, cold food, and/ or cold air on affected area. Temporal Arteritis:  Indurated temporal artery , pain felt behind eye/scalp.  NOTE: if untreated may lead to blindness. Hematological System Review Tips Acute Hemorrhage  Blood loss of 15% or higher usually results in orthostatic hypotension. The initial H/H during acute blood loss will not shop anything abnormalities till 24 hours after the onset of the hemorrhage. Bone marrow responds by releasing immature RBC’s (reticulocytosis). Neutropenia  Defined as an absolute neutrophil count (ANC) of less than 1,500/mm3  NOTE: African American may have a lower ANC count that is benign in nature. Meaning that the bone marrow aspirate is normal. Vitamin B 12 Deficiency  Gradual onset of of symmetrical peripheral neuropathy starting in the feet and/ or arms.  Clinical Manifestations: o Numbness o Ataxia (positive Romberg’s test) o Tetracycline antibiotics, levothyroxine, and Bisphosphonates decrease the effectiveness, so pt’s must take iron 2 hours before or after the above listed medications.  Failure to respond to treatment: may be a sign of continuous blood loss, misdiagnosis (i.e. thalassemia instead of iron deficiency anemia) and/ or malabsorption (Celiac disease). o Iron Poisoning: very serious in children (especially < 6 years of age) may cause death. Advise patients to store in an area away from children.  NOTE: in a person with healthy bone marrow, supplementing the deficient substance (whether that be iron and/ or B12) will cause the H/H to increase starting at 1-2 weeks and be back to normal within 4-8 weeks. Medications that lower H/H and/ or worsen anemia. o ARB’s and ACEI’s in patient’s of chronic diseases such as CKD, DM, HF, and HTN. Pernicious Anemia  Vit B 12 deficiency  Parietal antibody test (antiparietal antibody and/ or intrinsic factor antibody test are elevated then Pernicious Anemia is diagnosed.  Macrocyctic/Megaloblastic, normochromic anemia.  Neurologic S/S: gradual onset of peripheral neuropathy starting in the feet and/ or arms, numbness, ataxia, loss of vibration and position sense, as well as impaired memory. Sickle Cell Anemia  Gold standard diagnosis is hemoglobin electrophoresis, but a cheap screening test for sickle cell is Sickledex.  Every state in the U.S. requires all newborns to be screened for sickle cell anemia.  NOTE: 1/5 African Americans in the United States has sickle cell. Deficient B12  Missing a diagnosis of B12 can result in in irreversible neurological damage.  Serum B12 levels are normal in up to 5% of patients with vitamin B12 deficiency, so also check antibodies, urine, MMA, etc.  NOTE: any patient where neuropathy and dementia are suspected the vitamin B12 should be checked. Musculoskeletal Exam Tips MRI:  Gold standard test for assessing any joint damage.  Used for Soft tissue injuries.  Used for tendons, cartilage, and meniscus injuries. XRAY:  Show bony changes or narrowing of joint space (OA) but does not show soft tissue injuries. Thumb Spica Cast  Also known as a splint is used for fractures of the wrist. NSAID’s  Cause and increase risk for cardiovascular issues, renal damage, and GI bleeding.  Experts states that dramatic Response to NSAID’s is helpful with diagnosing ankylosing spondylitis. Degenerative Joint Disease (DJD or OA)  Occurs when the cartilage covering the articular survace of joints become damaged.  Clinical Manifestations o Early morning stiffness with inactivity. o Short duration of pain (usually less than 15 minutes) o During exacerbations the involved joint can often be swollen and tender to palpation. o HeberDen’s Nodes : bony nodules located in the distal interphalangeal joints (DIP). o Bouchard’s Nodes: Bony nodules located on the proximal interphalangeal joints (PIP)  Treatment for DJD and/ or OA : Pharmacologic / non pharmacologic  Non-Pharmacologic management: o Exercise at least 3 times weekly (with care though)  Isometric exercises to strengthen the quadriceps muscles (knee OA).  Weight bearing: walking , lifting weights, and resistance bands. o Avoid aggravating activities o Use cold or warm compresses o Walking aids o Alternative Meds:  Glucosamine supplements  SAM-e  Tai Chi  Acupuncture  Pharmacologic Management o Analgesics (Tylenol is 1st line defense. (325 to 650 mg every 4-6 hours. o NSAID’s (PO and topical) o Steroid injections on inflamed joints, but no systemic / PO steroids. o Surgery: i.e. joint replacement. Medial Tibial Stress Fracture or Syndrome  Lower extremity injury caused by overuse resulting in microtears and inflammation of the lower muscles, tendons, and bone tissue of the tibia. Also known as: “Shin Splint”  Risk factors: o Runners o People with flat feet o Woman at higher risk for stress fracture. Especially those with “female athlete triad” – amenorrhea, eating disorders, and osteoporosis.  Clinical Manifestations: o C/O of recurrent shin pain in one and/ or both legs that becomes worse over time. o Pain located at the inner border of the inner border/inside edge of the tibia that usually occurs after exercise. o Mild swelling o Focal area of tenderness that is painful to palpation is suggestive of stress fracture. o NOTE: if pain description is vague and it is not tender to palpation is is medial Tibial stress syndrome. Rheumatoid Arthritis  Systemic autoimmune disorder that causes inflammation of multiple joints and possibly joint damage.  NOTE: these patients are at higher risk for other autoimmune disorders such as Graves disease, pernicious anemia, and etc.  Risk Factors: Woman 8:1  Clinical Manifestations: o Gradual onset of symptoms over months’ time frame. o Fatigue o Low-grade fever o Myalgia o Early morning stiffness with pain and warm, tender, and swollen fingers in the DIP, POP joints (also called sausage joints). Usually lasts for 1 hour and has been present for more than 6 weeks. o Joint involvement is usually symmetrical with more joints involved than DHD o Most common affected joints: hands, wrist, elbows, ankles, feet, and shoulders. o Rheumatoid Nodules o Swan Neck Deformity: flexion of the DIP joint with hyperextension of PIP joint. o Boutonniere Deformity: Hyperextension of DIP with flexion of the PIP joint.  Labs o Sedimentation Rate- ^ o CBC: mild microcytic or normocytic anemia is common. o RF o Radiographs: Bony erosions, joint space narrowing. Subluxations (or dislocations)  Treatment o Refer to Rheumatologist o Surgery: joint replacements if necessary. o Careful assessments b/c you never want to prescribe an Biologic or anti-TNF medications if any signs of infection, are present. (Ex. fever and/ or sore throat)  Pharmacologic o NSAID’s o Steroids (systemic) o Steroid joint injections (synovial space o Disease Modifying antirheumatic drugs (DMARDS): methotrexate, Sulfasalazine, cyclosporine, and/ or Hydroxychloroquine (antimalarial drug) o NOTE: if poor response to non-biologics DMARD’s use other biologic agents, tumor necrosis factor (TNF), and/ or alpha inhibitors. o Bowel and Bladder incontinence (usually new onset) o Saddle Anesthesia – loss of sensation restricted to the area of buttock, perineum and inner surfaces of thighs. o Sciatica  Treatment: EMERGENCY refer to ED for decompression and/ or surgical intervention. Fracture of the Wrist  Thumb spica cast Baker’s Cyst  Type of Bursitis that is located behind the knee (popliteal fossa). Inflammation of the Bursae. Bursae is a protective fluid-filled synovial sacs located on the joints that act as a cushion and protect the bones, tendon’s, joints, and muscles. Sometimes when there is injury and /or damage done to the joint it can cause an increase in the synovial fluid, thus causing the bursa to enlarge.  Clinical Manifestations: o C/O of ball like mass behind one knee that is soft and smooth in nature. o Can cause pressure like pain or be asymptomatic o If cyst ruptures it will cause inflammatory reaction that often resembles cellulitis on the surrounding area (the calf).  It will present as redness, swelling, and/ or tenderness of that site.  Diagnostics o Diagnosed by clinical presentation and history, but if uncertain than MRI is done o Rule out plain bursitis from bursitis with infection i.e. septic joint.  Treatment o RICE o NSAID’s as needed o Large Bursa can be drained using 18-gauge syringe. Synovial fluid should be clear and golden in color. If cloudy fluid is aspirated as well as presence of redness, swelling, tenderness, hot, order C&S to rule out septic joint infection. Psychosocial Mental Health Exam Tips Minor Depression vs. Major Depression  Depression is a dysfunction of neurotransmitters serotonin and norepinephrine that has a strong genetic predisposition.  Clinical Manifestations o Mood- tearful or depressed mood most of the time. o Anhedonia- decreased interest or pleasure in most and/ or all activities. o Energy- fatigued or loss of energy o Sleep disturbances o Guilt- feelings of worthlessness or inappropriate guilt. o Concentration – diminished concentration o Suicide- recurrent/obsessive thought of death or suicidal ideations. o Weight- weight loss (>5% body weight) or weight gain o Agitation- Psychomotor agitation or retardations.  Diagnosis o Mild Depression - at least 2, but less than 5 of the above clinical manifestations. o Major Depression – 5 or more of the above clinical manifestations o Differential Diagnosis: R/O hypothyroidism, anemia, autoimmune, Vit B12 deficiency.  Management o Must assess for suicide, homicidal ideation, or if a plan is in place. o Refer to psychiatric hospital- must be driven by family member, friend, or EMS.  Screenings o Beck Inventory- contains 21 items. o Beck Inventory for Primary Care – Has 7 items and 99% specificity. o Two Item Questions  During the past month, have you felt down, depressed, or hopeless?  During the past month, have you felt little interest or pleasure in activities?  NOTE (Yes to any of the above is a + test.  Labs: o CBC, Chemistry, TSH, folate, Vit B12, and UA o R/O organic causes – i.e. drug use. Bipolar  Type 1 (Mania) and Type 2 (Hypomania).  Clinical Manifestations o Manic- increased energy, activity, grandiosity, decreased need for sleep, disinhibition (lack of self-restraint), and/ or euphoric mood. o Depression- psychotic episodes (delusions or hallucinations).  Bipolar pt’s have an increased risk for suicide, substance abuse, as well as other comorbidities (ADHD, anxiety, OCD, and/ or eating disorders).  Management: Refer to psychiatrist.  Medications- o Lithium salt- adverse effects of kidneys and thyroid gland. o Anticonvulsants- Valproate, carbamezapine o Antipsychotics – used to treat manic episode. Atypical Antipsychotics  Olanzapine (Zyprexa), Risperidone (Risperdal), and Quetiapine (Seroquel)  Adverse Effects: Obesity and DMII  Management: Monitor BMI and check weight every 3 months. Typical Antipsychotics  Haloperidol (Haldol), Chlorpromazine  Adverse Effects: elevated triglycerides and lipids, Malignant Neuroleptic Syndrome o Black Box Warning- use caution in frail elderly b/c ^ risk for death.  Management: have a fasting blood glucose and lipid profile. Adverse Effects for Antipsychotics  Pill-rolling (rolling the thumb and index finger over one another) shuffling gate, and bradykinesia.  Extrapyramidal Side Effects o Akinesia (inability to initiate movement) o Akathisa- inability to sit still o Bradykensia- slowness is movement o Tardive Dyskinesia- involuntary rapid movements. Anticonvulsants  Lamotrigine (Lamictal), Carbamazine (Tegretol), Valproate (Depakote)  Adverse Effects: Steven Johnson Syndrome (more common when taking Lamictal).  Management: Educate pt on the need to report rashes  NOTE- some of these medications are often used for mood stabilizer for bipolar disorder. SSRI’s  Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Celexa), and Escitaprolam (Lexapro).  1st line treatment for Major depression and OCD, but  Treats GAD, Panic Disorder, Social Anxiety, and Premenstrual Dysphoric Disorder o Smoking cessation – Buproprion (Zyban) in combination with nicotine avoidance meds o Neuropathy- Duloxetine (Cymbalta) –also used with neuropathic pain.  Takes up to 4-8 weeks (sometimes 12) to be effective, so wait that long to change dose.  Adverse Effects: o Sertraline (Zoloft)- anxiety o Paroxetine (Paxil)- Most likely cause of erectile dysfunction  Has a short half life and pt’s need to be weaned off b/c withdrawal S/S o Citalopram (Celexa)- Sexual side effects (good with elderly)  If sexual dysfunction occurs, consider adding Bupropion (Wellbutrin) in addition to SSRI. o Escitaprolam (Lexapro)- Serotonin Syndrome o Prolongs QT  Management: Avoid with anorexic patients as well as malnourished elderly.  Black Box Warning: increase risk for suicidal ideations and behavior in children, adolescents, n o Black Box Warning for suicidal ideations (Especially pt’s who are 24 years or younger) during initial treatment 1-2 months. o Elderly- Consider using Citalopram (Celexa) b/c fewer drug interactions. Atypical Antidepressants  Bupropion (Wellbutrin) and Zban for smoking cessation.  Adverse Effects: seizures  Management: Contraindicated with seizure disorders, anorexia or bulimia. SNRI  Venlafaxine (Effexor), Duloxetine (Cymbalta)  Adverse Effects- can precipitate acute narrow-angle glaucoma Anorexia  Irrational preoccupation with an intense fear of gaining weight in combination with distorted perception of body shape and size  Clinical Manifestations o Lanugo- fine soft hair noted throughout the body o Peripheral Edema o Amenorrhea o BMI <18.5  Complication o Increased risk for osteopenia and/ or osteoporosis due to prolonged depletion of estrogen (secondary to amenorrhea), low calcium intake. o Increased risk for pathologic fracture Abuse  Types of Abuse o Physical Abuse o Emotional Abuse o Sexual Abuse o Neglect o Economic Abuse o Material Exploitation o Elderly Abuse  Common in frail elderly with dementia.  2/3 of all elder abuse is perpetrated by family  Most abused elderly suffers economic abuse Common Findings of Abuse  Delay in seeking medical treatment  Intimate Partner Violence – defined as intentional control or victimization performed by a person to another with whom the person has an intimate or spousal relationship with. o Biggest reason for missing this diagnosis is failure to ask. Risk Factors that increase the likelihood of Abuse  Increased Stress  ETOH/Drug abuse  Personal hx of abuse or familial history of abuse  Major loss (i.e. financial and/ or job)  Social Isolation  Pregnancy Physical Exam during Abuse  Another health care provider should be in room during exam.  Interview without abuser in room.  Collect visual evidence  Use the abuse assessment screening tool with body map to document findings.  Signs of Neglect o Dirty clothes, inappropriate dress for weather.  Partner abuse- focus on development of safety and crisis numbers  STD Testing- chlamydial, gonorrheal, HIV, Heb B, Syphilis, Herpes 2 as well as genital throat, and anal area cultures Abuser  Described as a person who does not want the abused person out of sight or interviewed alone.  The abuser answers all questions and shows controlling behaviors toward patient. Exam Tips on Abuse  Abuse cases interview together and separately.  Any answer choice that reassures patients is always wrong.  Delaying and action is always wrong- i.e. – waiting until the pt feels better. Men’s Health Review Exam Tips Finasteride (Proscar)  MOA: inhibits Type 2- 5 Alpha Reductase, thus blocking androgen receptors and acts directly on the prostate gland to shrink it (temporarily) . Once the patient stops taking medication the prostate will go back to it’s original size.  Prostate shrinks by 50% while on Proscar, so PSA must be doubles or multiplied by 2.  Category X- teratogenic, so it should not be touched with bare hands by any female of reproductive age. Males with hypertension and BPH-  1st line treatment is to start on alpha-blockers (Hytrin)  Works by relaxing smooth muscle on prostate gland and bladder neck. Chronic Prostatitis Vs. Acute Prostatitis Chronic Prostatitis  Infection of the prostate for > 6 weeks  Pathogen- E. Coli or Proteus.  Clinical Manifestations o Suprapubic or perineal discomfort o Irriitative voiding symptoms – Dysuria, Nocturia, and / or Frequency o Prostate – may feel normal or slightly “boggy” to palpation, but not tender. o Elevated PSA due to inflammation.  Diagnostics o UA - Normal unless cystitis is present and urine can be mixed with prostatic fluid, thus being positive for E. Coli. o Prostatic Fluid Cultures  Management o Bactrim PO BID for 4-6 weeks if sensitive. o Ofloxacin (Floxin) or Levaquin daily for 4-6 weeks. Acute Prostatitis  Acute infection of the prostate when the infection ascends into the urinary tract.  Clinical Manifestations o High fever o Chills o Suprapubic and/ or perianal pain that sometimes radiates to back or rectum. o UTI symptoms- dysuria, frequency, nocturia, cloudy urine. o Prostate – Warm, boggy, and very tender to touch. o Infection can and/ or will occur in the bladder, or epididymitis.  NOTE: If acute infection occurs in a male younger then 35, it is likely due to gonococcal and chlamydial urethritis  Diagnostics o CBC- leukocytosis with shift to the left – i.e. presence of band cells. o UA- large amount of WBC in urine (pyuria) o Urine C&S- if possible obtain after DRE with gentle prostatic massage. Priapism  Prolonged and painful erection for several hours (2-4)  Risk Factors o High doses of or ED meds o Cocaine o Quadriplagia  Ischemic form is a medical/surgical emergency. Testicular Cancer  Risk Factors: o White males 15-30 years of age.- VERY RARE in African Americans. o History of Cryptorchidism (undescended testes)  Clinical Manifestations: o Usually painless and asymptomatic till metastasis. Then C/o of nodule, sensation of heaviness or aching o One testicle being larger than the other. Prostate Cancer  Risk Factors: o More common in African Americans > 50 years of age who are obese with strong familial history of prostate cancer (i.e. brother and / or dad) .  Clinical Manifestations o New onset of low back pain, rectal area/perineal pain. o Obstructive voiding symptoms- weaker stream and/ or nocturia. o Sometimes can be asymptomatic.  Anorexic and/ or Bulimic pt’s- avoid Depo-Provera b/c very high risk of osteoporosis.  Seasonale- only 4 periods a year.  Menstrual Pain: Mefenamic Acid (Ponstel), NSAID that is very effective for menstrual pain.  Plan B, My Way, or Next Choice (all EMERGENCY contraceptives) o Take 1st dose 72 hours within unprotected sex or if 2 days of pill is missed, but NEED to r/o pregnancy first. o Take 2nd dose 12 hours after the 1st dose. o 89% effective. o Educate pt that if she will not have a period in next 3 weeks, return to r/o pregnancy.  Contraindications of PO contraceptive use o Any hx or condition that increased clotting o Smoker > than 35 year of age (more than 15 cigarettes a day). o Any condition that increase the risk of stroke  Migraine with aura or without aura and greater than 35 years of age  HX of CVA or TIA  History of HTN o Inflammation or Infection of the liver  Mono, Hepatocellular adenomas or malignancy of liver, or cholestatic jaundice of pregnancy  NOTE- once the LFT’s are back to normal they CAN go back on BC. o Known or suspected cardiovascular disease: CAD, DM with vascular component, Lupus, HTN with SBP > or = to 160. o Reproductive conditions or Cancers  Pregnancy, undiagnosed genital bleeding or breast mass.  Any breast, endometrial, or ovarian cancer (i.e. any estrogen-dependent cancers).  Less than 21 days’ post-partum. o Fracture or cast on lower extremities (i.e. increased risk of clot). o Mnemonic “My CUPLETS”  My- migraines with focal or neurological aura  C- CAD of CVA  U-undiagnosed genitial bleeding  P- pregnancy or suspected pregnancy  L- liver tumor or active liver disease  E- estrogen dependent tumors  T- thrombus or emboli  S- smoker age 35 or greater.  Cu-IUD o Last 10-12 years o Has the Broadest indication of use for woman with medical conditions such as DM, smokers >35 years of age, on anticonvulsants, on antiviral therapy, ovarian cancer, ischemic heart disease, and/ or liver tumors.  Progesterone IUD – Mirena last 5 years.  Yaz/Yasmin – o Contains estrogen and drospirenone- o Increase risk for blood clots, stroke, and/ or heart attacks.  Depo-Provera- do not recommend for woman who want to become pregnant in 12-18 months, because it can take up to 1 year for woman to start ovulating again. Bisphosphonates  1st line drug for treating post-menopausal osteoporosis, glucocorticoid-induced osteoporosis, (men and woman), and osteoporosis in men.  Fosamax (Alendronate) - 5-10 mg daily or 70mg weekly.  Actonnel (Risedronate- 5 mg daily or 35 mg weekly or 150 mg monthly  Very potent esophageal irritant – pt to report sore throat, dysphagia, midsternal pain. o Can cause- esophagitis/ esophageal perf, gastric ulcers, reactivation/ bleeding, or PUD.  How to take? o Take immediately when you wake up with 6-8 onces of water (not mineral water), while sitting up. o Must sit or stand for at least 30 minutes before lying down. o Do not crush, split, or chew, but only swallow whole o Ever combine these meds with other meds or juice, coffee, antacids, or vitamins. Bone Density  Osteoporosis - > -2.5 SD  Osteopenia- T- score is -1.5—2.4 SD Bacterial Vaginitis  Caused by an overgrowth of anaerobic bacteria in the vagina.  Risk Factors: Sexual activity, New or multiple sexual partners, and Douching  NOTE – not an STD, so therefore sexual partner does not need to be treated.  Pregnant woman with BV- higher risk for intrauterine infections and premature labor.  Clinical Manifestations o Unpleasant fish like odor- usually worse after intercourse o Copious amounts of milk-like consistency vaginal discharge. o Speculum Exam- revels off white to light-gray discharge coating the vaginal wall. o NO vulvar or vaginal redness or irritation b/c vaginal anaerobic bacteria does not cause inflammation.  Diagnostics. o Labs:  Wet Smear Microscopy – clue cells and very few WBC’s  Clue Cells are squamous epithelial cells that have blurred edges due to the large number of bacteria on the cell’s surface.  Mobiluncus Bacteria usually about 82% of the time  Gram (-) anaerobic bacteria will show rod-shaped bacteria. o Whiff Test- apply 1 drop of KOH to swab that is soaked with vaginal discharge.  Positive Test- a strong fishy odor is released. o Vaginal Ph- Alkaline vaginal pH is greater than 4.5  NOTE- Normal pH is between 4.0-4.5 Acidic)  Treatment o Flagyl BID- 7 days o Metronidazole vaginal gel one applicator at HS for 5 days.  Pt education o Do not drink with flagyl b/c it will cause Antabuse effect Refrain from sexual activity during treatment. Candidal Vaginitis  Overgrowth of Candida albicans yeast in the vulva/vagina. It can be considered a normal finding, but also be pathogenic in nature as well.  Risk Factors o DM o HIV + o Antibiotics use o Immunosuppression  NOTE- male penis can also be infected with this (balanitis).  Clinical Manifestations o White cheese-like (curd-like discharge) o Severe vulvo-vaginal pruritus (external and internal). o Swelling o Redness  Diagnostics o Wet smear microscopy-  Pseudophyphae, spores, and large amount of WBC’s.  Treatment o Miconazole (Monistat), Clotrimazole(Gyne-Lotrimin) OTC for 7 days o RX: Diflucan 100mg X 1 dose, Terconazole (Terazol-3) vag cream/suppository.  NOTE- if pt on abx recommend daily yogurt or lactobacillus pills. Trichomonal Vaginitis  Unicellular protozoan parasite infection with fragella that infects GU tissue (in both males and females) that causes inflammation.  Clinical Manifestations o Very pruritic and red vulvo-vaginal area. o Dysuria o Copious amount of grayish, green, and bubbly vaginal discharge. o Male partners- may have c/o of dysuria, frequency(urethritis) or by asymptomatic.  Objective findings o “Strawberry Cervix” from small points of bleeding on cervical surface (punctate hemorrhages) o Swollen and red vulvar and vaginal area. o Vaginal pH greater than 5.0 o Dysuria.  Treatment o Flagyl 2g PO X1 dose (preferred) or 500 mg BID X7 days.  HSV-2 more common on genitals. o Imiquimod is an immune-modulator at home treatment ofr warts.  1st episode treatment is Zovirax, Valtrex, or Favier BID X 5 days. Fitz-Hugh-Curtis  Usually is a complication of PID chlamydial and/ or gonococcal infection of the liver capsule (not the liver itself) that causes extensive scarring between the liver capsule and the abdominal contents.  Usually is a complication of PID due to chlamydia  Clinical Manifestations o Scars look like “Violin Strings” o RUQ abdominal pain with tenderness of palpation. o LFT’s are normal  Treatment o Treated as complicated gonorrhea/chlamydial infection o Rocephin 250 mg IM + Doxy PO BID X14 days. Jarisch-Herxheimer Syndrome  An immune-mediated reaction that occurs within the first 24 hours after treatment of Syphilis and other Spirochete infections (i.e. Lyme Disease).  Clinical Manifestations o Acute onset of fever and chills o Headache o Myalgias  Resolves spontaneously within 12-24 hours  Treatment – supportive measures only. Disseminated Gonorrheal Infection (DGI)  New onset of swollen red knee on side (or other joints) Tips  Any treatment with Azithromycin (X1 dose) (Chlamydia) the patient should be instructed to not have sex for at least 7 days.  Treatments Contraindicated for Pregnancy o Podofilox, Podophylia, imiquimod  Pregnancy Warts- treated only with mechanical methods- (i.e. curio, loser, excision, and/ or etc..  HPV strains 16 and 18 are oncogenic/carcinogenic  Tzanck smear shows multinucleated giant cells with herpes virus infection (i.e. varicella, herpes simplex).  Genital Herpes – treatment duration o 7-10 days for treating primary genital herpes infection. o Breakouts duration is 5 days. Woman’s Health, Pregnancy, and Childbirth Review Presumptive Signs of Pregnancy  Palpation of fetal movement (quickening) by mother is presumptive sign of pregnancy.  Amenorrhea  N/V (most common in 1st trimester) in the AM usually disappears in 2nd trimester.  Breast Changes (swollen and tender)  Fatigue  Urinary frequency  Sunlight increase in body temperature. Probable Signs of Pregnancy  Urine/Serum Pregnancy – are probable signs of pregnancy not positive because Beta hCG are also present in molar pregnancies as well as ovarian cancer.  Goodell’s sign- (4 weeks)- cervical softening  Chadwick’s Sign- (6-8 weeks) blue coloration of the cervix and vagina.  Hegar’s Sign- (6-8 weeks) softening uterine isthmus.  Enlarged Uterus  Ballottement (seen in mid-pregnancy) – this occurs when the fetus is pushed, it can be felt to bounce back by tapping the palpating fingers inside the vagina.  Urine or blood pregnancy test (hCG). Positive Signs of Pregnancy  Palpation of fetus by health provider.  US and visualization of fetus.  Fetal heart tones (FHT’s) auscultated by health provider. o 10-12 weeks by Doppler/Dopstone. o 20 weeks by fetoscope/stethoscope. **** NOTE: During the exam questions asking for one of the signs will mix them up (i.e. positive signs with a probable sign) on the exam. Make sure the answer option contains the two signs of the same category. **** **** NOTE: Memorize 3 of the positive signs of pregnancy b/c this is the shortest list, so by process of elimination, you can rule out and/ or in the correct answer. **** Naegele’s Rule  LMP month on the xam will either be Janurary 01, February 02, or March 03. o January- EDD is October o February- November o March- December Placenta Previa  Pregnant woman who is in the late 2nd or 3rd painless vaginal bleeding (bright red) that worsens with sexual intercourse.  Clinical Manifestations- o Uterus is soft non-tender o Cervix is not dilated  Management o Strict bed rest o IV magnesium if there is uterine cramping present. o Usually uterus will replant itself in mild cases o NOOOOooooo rectal insertion or stimulation of any kind (can precipitate vaginal hemorrhage).  If cervix is dilated or hemorrhage occurs STAT C-section is needed Placenta Abruptio  Occurs in late 3rd trimester of pregnancy with PAINFUL vaginal bleeding that is intermittent with hypertonic, hard, and tender uterus.  Clinical Manifestations o Dark-red colored vaginal bleeding.  Risk Factors- in patients with HTN, preeclampsia/eclampsia, cocaine use, or history of abruption placenta in the past. Fundus Location Correlated to Gestational Age  12 weeks- above symphysis pubis  16 weeks- between the symphysis pubis and umbilicus  20 weeks at the umbilicus Gestational Diabetes Mellitus (GDM)  Diagnosed in 2nd or 3rd trimester.  Woman with DM in their 1st trimester DMII  A woman with A1C <6% (2nd-3rd trimester) have the lower risk for LGA infants.  Risk Factors o Previous history of GDM o Obesity o Ethnicity- Asian, Native American, Pacific Islander, Blacks, Hispanic). o Macrosomic infant (> 9 lbs) o 35 year of age or greater.  Screening (2 methods) o Screen at 1st visit if hx of GDM and/ or presence of risk factors. o 1-step uses the 75gu- OGTT (both for screening or diagnosis) o 2-step uses 50g OGTT test (non-fasting as the screening rest0. o If 50gOGTT is abnormal (i.e. >140mg/dL or fasting >95g/dL a follow up test of 100g OGTT is needed. (MUST FAST FOR 8 HOURS).  Management o 1st line treatment for GDM- lifestyle changes (i.e. diet and exercises). Rh-Incompatibility Disease o If present past 6 months it is indicative of brain damage. Immunization Tips  Do not give varicella and MMR vaccine before age of 12 months.  Youngest age for influenza vaccine is 6 months.  Only vaccine given at birth is Hep B  If there is a HBs-A positive mother – give the neonate Hep B immunoglobulin (HBIG) and the Hep B vaccine.  Do not use DTap vaccine if age 7 years or older. Instead use Td or Tdap form of vaccine.  Give Tdap vaccine at age 11 or 12 years as a booster. o IF older replace one dose of Td with Tdap (NOTE- only once / per lifetime).  NOTE- any vaccine that does not have a time range will NOT appear on exam. o i.e. IPV can be given from 6-18 months or 3rd dose of Hep B can be given between 6- 8 months. Developmental Dysplasia of the Hip (DDH)  Risk Factors- breech births, females, familial hx, or oligohydraminos (not enough amniotic fluid).  Screening: 0-3 months o Ortolani- hold each knee and place your middle finger over the grater trochanter (outer thigh over the hip), then rotate the hips in the frog leg position, (abduction then adduction). During abduction resistance may be felt at 30-40 *s.  Positive- “Click” or “Clunk” sound and/ or if examiner palpates the trochanter becoming displaced (temporarily) from the hip socket. o Barlow- Place your index and middle finger over the greater trochanter. Then gently push both knees together at midlines, downward, then pull upward. Will hear “clunk” sound when the trochanter slips back into the acetabulum (reducible dislocated hip)  Positive- “Clunk” sound or plapating trochanter being displaced by the index/ middle finger. Exam Tips  Asymmetry of thigh, gluteal folds – r/o congenital hip dysplasia or hip fracture. Coarctation of the Aorta  Congenital narrowing of a portion of the aorta (i.e. usually the aortic area that is distal to subclavian artery).  Can by asymptomatic or symptomatic (i.e. HF and/ or shock when PDA closes).  Screening o Compare femoral and brachial pulses simultaneously. If there is an absence or delay of the femoral pulse when compared to brachial pulse it is diagnostic. o Neonates- pale, irritable, dyspeneic, and/ or diaphoretic.  Management o If abnormal order Echo, EKG, CXR.  Normal Findings- Systolic BP is higher in legs than in arms.  Abnormal Findings- systolic BP high in arms than in thighs, Palpate pulse in all four extremities. If there is a delay or change in amplitude of pulses. (i.e. bounding radial pulses compared with femoral pulse). Toddlers Review (age 2-3) Wilms’ Tumor (Nephroblastoma)  An asymptomatic congenital tumor of the kidneys (Does it cross the midline?)  Risk Factors: More common in African American girls.  Peak age: 2-3  Clinical Manifestations o Abdominal pain o Hematuria o HTN occurs in ¼ of all patients.  During exam palpate gently to avoid rupturing the renal capsule b/c it can cause bleeding, seeding of the abdomen with cancer cells.  Imagining: Abdominal US Epiglottitis  Acute and rapid onset of high fever, chills, and toxicity.  Clinical Manifestations o High fever (chills) o Severe sore throat o Drooling saliva o Muffled (hot potato) voice o Anxiety o Sitting posture with hyperextended neck with open-mouth breathing. o Stridor o Tachycardia o Tachypnea  Peak Age: 2-6  Management o Preventative – HIB vaccine o Prophylaxis for close contacts- Rifampin for 4 days o Reportable Disease Developmental Tips  6 months o Should be able to roll in both directions at  9 Months o Plays peek-a-boo, paddy cake, and cruises (holding on to furniture to walk).  2 years old – o Speech is understood by family members  3 years old – o speech can be understood by strangers o Ride tricycle o Copy circle  4 years’ old o Copy a cross o Draw a stick person with 3 body parts  5 years’ old o Can draw a person with at least 6 body parts.  6-7 years’ old o can ride a bicycle  Oedipal stage- when the child (usually 3-6 years of age) express the desire to marry the parent of the opposite sex. Autism Spectrum Disorder  Collects of signs and symptoms that appear as early as 18 months.  Peak Age: 2-6 years of age  Clinical Manifestations (5 behaviors to look for) o Does not point, wave, or grasp by 12 months. o No babbing or cooing by 12 months. (no single words by 16 months) o Does not say 2 phrases on his/her own. o Any loss of language or social skills by 24 months. o Do not gesture (waving, grasping, an/d or pointing) by 24 months. School- Aged Children (including preschool) Tips  11 to 12-year-old children should be vaccinated with single dose of the quadrivalent meningococcal vaccine (MenACWY) i.e. Menectra or Menveo are the brand names.  Immunizations needed at age 11-12: Tdap, HPV, MCV4.  11 years old – “Early Abstract” thinking stage (Piaget).  HPV vaccine (Gardasil) – youngest age group for administration is 9 years of age. Hand Foot Mouth Disease  Common acute viral infection usually caused by the coxsackievirua A16.  Peak Age: < 10 years of age.  Transmission: o Direct contact with nasal discharge, saliva, blister fluid, and/ or stool. o Most contagious during the first week of the illness.  Clinical Manifestations o Acute onset of fever o Sore throat o Headache o Anorexia o Rash presentation  Multiple small blisters appearing on hands, feet, and diaper area.  Ulcers are common inside the mouth, throat, tonsils, and the tongue. Puberty  Starts at Tanner Stage II in o Girls (i.e. breast buds). o Boys (i.e. testicular enlargement and scrotal rogation/color becomes darker).  Tanner Stage III o Boys- elongation of the penis (testes continue to grow). Tips  Adolescents health hx is obtained from both parent and child initially, then the adolescent is interviewed alone without parent. Emancipated Minor  Minors may give full consent as an adult without parental involvement.  Legally married and active duty in the armed forces. Right to Consent and Confidentiality  No parental consent is necessary for the following o Contraception o Treatment for STD’s o Diagnosis and Management of pregnancy  Consent NEEDED for dysmenorrhea, headache, upper respiratory infections. Anorexia Nervosa  Usually onset is during adolescence  Irrational preoccupation with and intense fear of gaining weight.  2 types: Restrictions or Bing eating and purging. o Purging examples consist of use of laxatives, enemas, diuretics, vomiting.  Clinical Manifestations o Lanugo- fine soft/downy hair (especially in the face, back, and shoulders). o Peripheral edema (RT low albumin) o Amenorrhea o > 10% of body weight loss. (BMI < or equal to 18.5) o Low Pulse: < 40 o Hypotension (dizziness) o Stress fractures (increased risk for osteopenia or osteoporosis, due to lack of estrogen depletion and low calcium intake). o Abdominal bloating Scoliosis  Screening o Adam’s forward Bend Test: bend forward with both arms hanging free. Look for symmetry of spine, scapula, thoracic, and lumbar curvature.  Curve Management o Curves less than 20 degrees- observe and monitor for changes in spinal curvature. o Curves 20-40: Bracing (i.e. Milwaukee brace) o Curves > 40: Surgical correction with Harrington rod is use on spine and other options. o NOTE: rapid worsening of curvature is usually due to secondary cause: Marfans, Ehler-Danlos Syndrome, Cerebral Palsy, Myelomeningocele).  Management o Check Tanner Stage (II-V) o Order spinal X-Ray (PA view) to measure Cobb angle. o Refer all patients with Scoliosis to Pediatric Orthopedic Specialist. Klinefelter Syndrome  Condition in which males are born with an extra X Chromosome and causing a primary hypogonadism (i.e. deficiency of testosterone).  Clinical Manifestations o Testicles are small and firm with small penis. o Tall stature o Wide hips o Reduced facial and body hair o Increased Risk for osteoporosis  Management: Replace Testosterone and Fertility treatment. Osgood-Schlatter  Is the most common cause of knee pain in young athletes that is caused by over use of the knee secondary to repetitive stress on the patella tendon by the quadriceps muscle.  Usually occurs during a growth spurt.  Usually on effects 1 knee but can be bilateral.  Common with adolescent males that play basketball, soccer, and/ or running.  Clinical Manifestations o Presence of bony mass on the the anterior tibial tubercle that is tender to touch. o Pain/Tenderness worsened by squatting, kneeling, jumping, or climbing stairs) o Swelling at the tendon’s insertion site (i.e. Tibial tuberosity).  Management o RICE (use ice TID 10-15 minutes) o Avoid aggravating activity, but adolescents can play based off severity of pain. o Majority of cases resolve spontaneously within a few weeks to months. o NOTE *** - R/o avulsion fracture (tibial tubercle) if acute onsets of pain post trauma occur. (i.e. X-Ray the knee). Primary Amenorrhea vs. Secondary Amenorrhea Primary amenorrhea  No menarche by age 15 (regardless of secondary characteristics) that is usually caused by chromosomal disorders (i.e. Turner Syndrome).  Puberty is delayed if there is no breast development by age 13, absence of pubic hair at age 14, and no menarche by age 15. Secondary Amenorrhea  No menses for 3 cycles or 6 months if previously had menses.  Usually caused due to pregnancy, but could also be caused by ovarian disorders, stress, anorexia, and/ or PCOS. Gynecomastia vs. Pseudogynecomastia Gynecomastia:  Excessive growth of breast tissue in males that is benign in nature and most often occurs during infancy and adolescence. Resolves spontaneously within 6 mo – 2 years. Pseudogynecomastia:  Enlarged breast due to fatty tissue that is common in obese patient’s. Seborrheic Keratosis Vs. Actinic Keratosis Seborrheic Keratosis:  (BENIGN) Soft wart like growth that looks pasted on. Usually found on back or trunk. Color can range from tan, brown, to black. Actinic Keratosis:  Precursor of squamous cell carcinoma. Presbycusis  Sensorineural type of hearing loss (inner ear) that usually with high frequencies (i.e. speaking voice).  Caused by degenerative changes of the ossicles, few auditory neurons, and/ or atrophy of the hair cells.  Usually starts at age 50. Arcus Senilis (Corneal Arcus)  Opaque grayish to white ring in the margin of the cornea or on the periphery of that iris, that occurs gradually and not associated with vision changes.  Caused by deposition of cholesterol and fat. < 40 usually indicative of elevated cholesterol.  Management- check fasting lipids. TIPS  S4 in the elderly is NOT associated with HD symptoms and is considered normal.  Cellular Immunity is affected more by age than humoral immunity.  Top cause of death in elderly is heart disease. Macular degeneration  Loss of central vision fields results in los of visual acuity and contrast sensitivity.  May find Drusen Bodies  Yellow deposits under the retina that are usually due to lipids and or fatty protein.  Use Amsler grid to evaluate central vision changes.  Most common cause of blindness in USA Cataracts  Cloudiness and opacity of the lens and/ or its envelope (  Most common cause of blindness in DEVELOPING countries.  Increase sensitivity to glare of car lights (at night)  Red Reflex Test: Cataracts appear as grayish-to-white reflection. Alzheimer’s Disease  Accumulation of neurofibrillary plaques/tangles that causes permanent damage to brain.  Decrease of ATCH production  Average life expectancy of a person age 65 years or older when diagnosed: 4-8 years.  Clinical Manifestations: 3 A’s o Aphasia o Apraxia o Agnosia  Most common cause of dementia in the US. (vascular dementia is the 2nd most common cause of dementia in US). REFER ALL PAITNET’S WITH SUSPECTED ALZHEIMER’S DISEASE AND PARKINSONS TO NEUROLOGIST FOR DIAGNOSTIC WORKUP Parkinson’s Disease  Progressive neurodegenerative disease of dopamine receptors  Peak Age: 60 years old or after  Idiopathic Parkinson’s due to low B12 levels secondary to Levodopa (check B12).  Clinical Manifestations o Gradual onset o Classic 3 S/S are tremor, muscular rigidity, and bradykinesia o Cogwheel rigidity with difficulty breathing o Masked face o Mood disorders: anxiety and/or depression o Shuffling gait with poor balance. (Often falling due to postural instability). o Excessive day time sleepiness o Worsening Seborrheic Dermatitis: white scales and erythema.  Management: 1st line management is Levodopa (Sinement) immediate release. o Some clinicians postpone levodopa use in early onset (< 60 y/o) Parkinson’s disease b/c the higher incidence of Levodopa-related dyskinesia  NOTE: Cholinergic drugs can exacerbate or worsen signs and symptoms associated with Parkinson’s disease. Sundowning Phenomenon  Starting at dusk/sundown the patient becomes very agitated, confused, and/or sometimes combative. Symptoms resolve in the morning and seen more in dementia  Management o Avoid quiet dark rooms, so have well wit room with radio, TV, or clock. o Familial surroundings are very important, so do not move furniture and/ or change décor. o Avoids drugs that affect cognition (antihistamines, sedatives, hypnotics, and/ or narcotics. MAO-B Inhibitors (Selegiline (Elderpryl) or Rasagiline (Azilect)  MAO-B-I: breaks down dopamine, thus prolonging the action of dopamine in the brain.  Does not have the dietary restrictions like MOAI’s.  Do NOT combine with MAOI’s, SSRI’s  Adverse Effects: insomnia, jitteriness, hallucinations.  Allow 14 days to pass before starting another drug that affects serotonin. Essential Tremor  Essential tremor is an action, or postural tremor (NOT a resting tremor).  1st line treatment is propranolol (i.e. beta blockers). Tips  Ribbon like stools in older adults with iron-deficiency anemia- r/o colon cancer.  Actinic Keratosis is a precursor for squamous cell carcinoma. o A small rough pink to reddish lesion that does not heal.  When a person is asked to interpret a proverb that is an example of abstract thinking.  UTI is the most common cause of acute mental status changes in the elderly. o Order UA for all elderly patients that present with AMS or dementia. Professional Issues Review Ethical Guidelines and Advanced Practice Law Beneficence: To move and/ or prevent harm. Non-Maleficence: Protecting the patient from harm and/ or avoiding harm. Utilitarianism: The obligation to act in a way that is useful to or benefits the majority as a whole. Justice: Being fair and acting with lack of bias Health Insurance Portability and Accountability Act  Do NOT leave laboratory findings on a voicemail unless previously okayed with patient.  TPA (Third Party Administrator) is the organization that does the processing of claims and administrative work for another company. Ombudsman  A person who acts like a liaison between the patient and organization to investigate and mediate the complaint form both sides in an attempt to reach a fair conclusion. Guardian Ad Litem  An individual who is assigned by a court to act in the best interest of the ward (i.e. usually a child or someone who is frail or vulnerable). Hospice  If patient meets all requirements for Hospice care, Medicare A will reimburse hospice. Medicare B  Will only pay for an ambulance for emergency care only, so if it is used for merely transportation purposes it will not be reimbursement.  Does not reimburse for dentures, glasses, or hearing aids. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)  Law that allows a person to continue group health insurance coverage from a job even if he or she has quit. However, the individual will have to pay the insurance premiums. TIPS  “Medical Home” is method of primary health care delivery where the providers deliver care in the patient’s home with the assistance of the family. Quality Improvement Program  Goal is to improve the quality of care, decrease complications, decrease hospitalizations, lower patient mortality, decrease system errors, as well as increase patient satisfaction.  Risk Management is an import aspect of quality-improvement and/ or quality assurance programs in the health care setting. Professional Roles and Reimbursement Claims Based Malpractice  Will cover claims only if the NP is still enrolled with the same insurance company at the time the claim is filled in court. Occurrence Type Malpractice Insurance  Will cover a lawsuit in the future even if you no longer carry the policy so long as you had an active policy during the alleged incident. TIPS  NP’s get their “right to practice” from the state legislature.  NPI: contains 10 numbers  Incident to billing- is used for Medicare patients and refers to billing of a follow-up visit performed by a non-physician provider billed under physicians NPI number. o The physician provider get billed for 100% and the the NP or PA will get 85%. Culture and Spiritually Related Beliefs Exam Tips  Muslim woman who refuse to wear a gown can be examined through her clothing (i.e. modified/ partial physical exam).