Hard to remember! (AACN AGACNP BOARDS) Questions and Answers

Hard to remember! (AACN AGACNP BOARDS) Questions and Answers Anion gap formula and normal value (Na + K) - (HCO3 + Cl) Normal AGAP: 4-12 Asthma pt & Beta Blockers use a cardioselective BB such as metoprolol or atenolol because nonselective BB (carvedilol and labetolol) can cause a s/e of wheezing/bronchospasm Glyburide (sulfonyurea) stimulate the release of insulin from beta cells/increase number of insulin receptors **contraindicated in elderly because they have low apetites (hypoglycemia risk) and not to be used in pt with GFR 60 Osteopenia vs. Osteoporosis Osteopenia: bone mineral density between -1 and -2.5 Osteoperosis: -2.5 (first line treatment is a bisphosphonate like Alendronate (fosamax). undergo DXA screening (bone density screening). also described as a metabolic bone disorder characterized by inadequete mineralization of the bone matrix. USPSTF recommends screening all women over age 65 but no repeat screenings ABI ankle brachial index normal range: 0.9 and 1.4. An ABI below 0.9 is PAD phenytoin (dilantin) normal range: 10-20. s/e: gingival hyperplasia Valproic Acid (Depakote) normal range: 50-100, 100 is toxic s/e: hepatotoxicity Glasgow Coma Scale (GCS) Eyes (4), Verbal (5), Motor (6) Ranson's score (used for Pancreatitis) George - greater than 55 years of age (70gallstone) Washington - WBCs 16,000 Got - Glucose 200 Lazy - LDH 350 After* - AST 250 -----------------------------------------------then 48 hrs later: He - Hct drop 10 Broke - BUN increase 5 C - Calcium 8 A - Arterial Pao2 60 B - Base deficit 4 E - Estimated fluid sequestration 6,000 ml patellofemoral pain pain around the rim of knee or back of knee usually caused by over use/going up stairs/hiking repeatedly "runners knee". pain around underneath knee. Tx: PT and strenghtening exercise best things... NSAID may help ganglion cyst fluid-filled sac arising from joint capsules or tendons, typically in the hand. transilliminates (differntiates from a solid mass). if any neuro symptoms like paresthesia/numbness/coolness get an ultrasound or MRI for vetter visualization Anterior Cruciate Ligament (ACL) injury Caused by sudden stop with change in direction. "popping sound". positive anterior drawer sign. positive lachman test ( iliotibial band syndrome an overuse injury caused by this band rubbing against bone, often in the area of the knee. pain starts when climbing stairs or running down hills. tx: rest, foam roll, ice, NSAIDS, ankylosing spondylitis a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae in the spine - causing stiff back it can affect almost any organ system. ts: NSAIDS, second line intrasrticular steroid injection for unrelieved pain Paget's disease a bone disease of unknown cause characterized by the excessive breakdown of bone tissue, followed by abnormal bone formation/remodeling USPSTF falls recommendation at increased risk, recommend PT or exercise. no Vit D recommendations. multifcatorial approachis selective when determining who needs it. posterior cruciate ligament tear most occur during a fall on the flexed (bent) knee or a crush injury. symptoms: joint effusion, internal pain and posterior drawer test* - treatment: PRICE, physical therapy and rehabilitation, surgical repair patellar tendonitis running injury, will not cause effusion. pain anteriorly. Meniscus tear apleys compression test can help identify laxity. pt reports "catching or locking" most common cause of fever of unknown origin in adults giant cell arteritis FRAX Tool (Fracture Risk Assessment Tool) Estimates risk of osteoporotic fracture in the next 10 years based off BMI, parental fcx history, and smoking h/o best DVT prophylaxis in hip fcx pt low molecular weight heparin trigger finger A condition whereby the finger flexors contract but are unable to reextend because of a nodule within the tendon sheath or due to the sheath being too constricted to allow for free motion. tx: splint and rest 3-6weeks usually resolves itself. stepwise NSAID, then steroid injection, and surgery if conservative management fails. before starting plaquenil for RA... must have an optho exam, cmp, cbc, and lfts Gonorrhea bacterial STD, often asymptomatic but can causedysuria and yellow-green discharge in men and women tx: ceftriaxone 250 mg IM x 1 dose sometimes add in azithromycin 1 g PO x 1 dose for chlamydia just in case chlamydia "C" *for most common STD* in US parastic STD, often asymptomatic, but can cause cloudy discharge, dysuria, postcoital bleeding tx: azithromycin 1 g PO x 1 dose or doxycylcine (vibramycin) 100 mg PO BID x 7 days Syphillis Chronic STD caused by a spirochete bacteria (treponema pallidum) primary- 1 yr; chacre is painless (indurated ulcer) at site of exposure secondary- flu slike symptoms, rash on palms/plantar sufaces and mucous patches, maliase, arthralgia, lymphadenopathy tertiary- leukopenia, AA, meningitis, cardiac failure, hemiplegia RPR test and FTA-ABS tx: primary/secondary - benzathine penicillin G 2.4 milllion units IM late, latent, or tertiary - benzathine penicillin 2.4 million units IM weekly x 3 weeks if penicillin allergic doxy 100 mg PO BID or erythromycine 500 mg PO QID STDs to tell health department chlamydia, gonorrhea, syphilis, and chancroid Vulvovaginitis types trichomonas, bacterial vaginosis, candidiasis Trichomonas a parasite causing an STD. malodorous yellow-green discharge, pruritis, erythema "strawberry patches" on cervix and vagina, dysparuenia and dysuria dx: saline mixture shows *motile trichomonads tx: metronidazole (flagyl) 2 g PO x 1 dose then 500 mg PO BID x 7 days Bacterial Vaginosis a fishy smelling discharge that is watery and gray. vaginal spotting. *no pruritis dx: saline mixture shows clue cells tx: Metronidazole 2 g PO x 1, then 500 mg PO BID x 7 days (could also do intravaginal BID) or... clindamycin vaginal cream Candidiasis yeast infection, thick white curd like discharge, vulvovaginal erythema with pruiritis dx: KOH mixture shows pseudohyphae tx: Miconazole (mono-stat) or clotrimazole 1% or 5 g intravginally x 7 days Terconazole 80 mg suppository x 3 days butaconazole 3 applications specificity the degree to which those how do not have a disease screen/test negative (SPIN - if you test positive it rules it "in") example.... HgbA1C is 94% specific... if you test positive it rules it in aka the degree to which you test negative is truly negative of diabetes.. aka i would test negative for a hgba1c it would b elow or normal because i do not have a disease which that test is specifically testing for DM sensitivity the degree to which those who have a disease screen/test positive (SNOUT - if you test negative it rules it out) Chancroid highly infectious nonsyphilitic venereal ulcer associated with high HIV transissions tx: azithromycin 1 g PO or ceftriaxone 250 mg IM x 1 dose or cipro 500 mg PO QD x 3 days Herpes A viral infection causing small painful blisters and inflammation, most commonly at the junction of skin and mucous membrane in the mouth or nose or in the genitals HSV1- (one finger is pointing up) up towards the face, lips, and mucosa which it involves HSV2- involves genitalia dx: viral culture or papanicolaou or txanck stain tx: no curative treatment but can treat with antipruritis drying agents too acyclovir (zovirax) recommended for topical/oral/IV use famciclovir valacyclovir - espeically helpful in asymptomatic viral shedding of HSV2 ST changes in all leads (diffusely) with PR depression pericarditis, chest pain relieved when sitting forward...tx: indomethacin (NSAID) orchitis/epidydmitis treatment Epididymitis is swelling or pain in the back of the testicle in the coiled tube (epididymis) that stores and carries sperm. Orchitis is swelling or pain in one or both testicles, Bed rest Elevate scrotum with folded towel Ice packs NSAIDs No medications for viral orchitis Bacterial orchitis - abx tx: think of treating gonorrhea (with ceftriaxone IM) and chlamydia (azithro or doxy) and if allergic to any, do an oxofloacin 5 W's of post-operative fever wind - atelectasis, PNA, IS, Chest pt water - uti, foley, pseudomonas walking - DVT, bone fracture, blood thinner? trauma, obese, wound - obese, smoker, surg site infection, elderly, malnutrition abx's wonder - drugs rxn, ss, nms, mh UTI uncomplicated UTI: 1st line - sulfamethoxazole/trimethoprim (bactrim) 1 tablet BID x 3 days if resistance is 20%, then give Nitrofurantoin (macrobid) 100 mg BID x 5 days complicated UTI- ciprofloxacin (cipro) 500 mg PO BID or 400 mc IV q12 hr for 7-12 days levofloxacin (levaquin) 750 mg orally or IV x7-14 days if patient has complicated UTI and multidrug resistance, give ertapenem 1 g IV daily, or piperacillin-tazobactam (zosyn) 2.226 g IV q6hrs, or cefepime 2 g IV q12hrs only treat asymptomatic uti in a pregnant patient (amoxicillin or cephelexin for pregnant patient or macrobid or bactirm before 3rd trimester) for complicated pyelonephritis immunocompromised patient, significant comorbidities pr pregnancy - hospitalize and IVPB deftriaxone 1 g QD, Levofloxacin IV QD, asymptomatic bacteriuria in a chronic foley patient do not treat it will cause resisitance and removal of ofley will lead to sponteanoeous elimination of bacteria Pink eye (Conjunctivitis) treatment Migraine treatment classic migraine (with aura) vs. common migraine (without aura) often a FMH, F.M, triggers: emotional/physical distress, lack or excess of sleep, missed meals, specific foods, alcohol, menstruation, OCPs, nitrate foods, changes in weather s/s: uniltaeral lateralized throbbing headache, focal neurodiscturbances may precede (aura). visual disturbances, aphaisa, numbness, tingiliung, nausea, vomiting, photophobia or phonophobia prohylactic chronic tx: avoid triggers, relax/stress management, and prophylactic therapy if more than 2-3 times per month: amitriptyline, propanolol, clonidine, verapimil, topiramate, magnesiu, acute tx: rest in dark quiet room, ASA, sumatriptan 6 mg SQ at onset, repeat in 1 hour (can give 3 times in one day) Cluster Headache treatment severe unilateral periorbital pain, ipsilateral eye redness, rhinorrhea tx: inhalation of 100% O2 sumatriptan (imetrex) 6 mg SQ ergotamine inhalation may be helpful too Tension Headache treatment most common type of headache (tight in quality) neck/back of head no neuro s/s tx: NSAIDS/amytriptiline in chronic Diastolic Murmurs MS. ARD Mitral Stenosis Aortic Regurgitation Diastolic Systolic Murmurs MR PASS MVP Mitral Regurgitation Physiologic/ Mitral Valve Prolapse Aortic Stenosis Systolic parkland formula for burns 4ml x KG x TBSA (1/2 vol in first 8 hours at onset of injury, last 1/2 over next 16 hours) TPA Contraindications/Precautions contraindications: -ischemic stroke/head trauma/neurosurgery in 3 months -previous intracranial bleed -active internal bleeding -intracranial neoplasm/AVM/aneurysm -Systolic BP 185/110* (check DBP) -Plt count 100,000 -On therapeutic anticoagluation -therapeutic arterial pncture at noncompressible site in past 7 days COPD FEV1/FVC less than 70% xxx CURB65 criteria scoring system to help with CAP disposition, but always consider clinical picture 1. Confusion 2. Urea (BUN 19) 3. RR 30 4. BP 90/60 5. Age 65 Result = hospitalize if 2+ or ICU if 3+ microcytic hypochromic anemia iron deficiency anemia and thalassemia normochromic normocytic anemia Anemia of chronic disease macrocytic normochromic anemia Folic acid and Vitamin B12 deficiency (pernicious anemia) Cushing's syndrome a condition caused by prolonged exposure to high levels of cortisol high Na, low K Addison's disease occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone high K, low Na Augmentin Unasyn Zosyn Bactrim amoxicillin-clavulanate ampicillin-sulbactam piperacillin-tazobactam Trimethoprim/Sulfamethoxazole Papilledema Stages Hypertensive Urgency vs. Hypertension Emergency Hypertensive Urgency is SBP 180 or DBP 120 Hypertensive Emergency is htn with end organ ichemia/damage such as ACS/HF/pulmonary edema/ARF/hematuria/encephalopathy/stroke/papilledema *monitor urine output, creatinine, and mental status (you may have lowered the BP too fast) Hypertensive Emergency- drop the BP by 25% in first few minutes to 2 hours. then, reach a goal DBP 110 within 2-6 hours... consider aline. utilize either nitroglycerin, nicardipine, labetolol, nitroprusside, esmolol. hypertensive urgency ok to use PO pills such as catopril, labetolol, clonidiine Look at Flip Book for Murmurs studying x Zollinger-Ellison syndrome hypersecretion of gastric acid that produces peptic ulcers as a result of a non-beta-cell tumor of the pancreatic islets Community Acquired Pneumonia no significant comorbidities --------------- (likely causitive organisms are S. pneumoniae, M. pneumoniae, C. pneumonia, influenza A/B, RSV) tx: oral doxycycline (usually for at least 5 days) or oral azithro/clarith/erythro (do not use if macrolide resistance rates is 20%) or, oral amoxicillin high dose comorbid patient (COPD, diabetes, renal, heart failure, asplenia, alcoholism) ---------------------------------- (likely causitive pathogens are S. pneumoniae, H influencase, M pneumoiae, C. pneumoniae, legionella sppp., respiratory viruses) tx: PO respiratory floroquinolone or doxycycline, or azithro or clarithro PLUS a betalactam such as augmentin or cefpodoxime or cefuroxime Hospital Associated Pneumonia early onset (5days in hospital), late onset 5d likely multidrug resistant low risk mortality: zoysn 4.5 g q6hr IV or levofloxacin or cefepime 2 g q8 hr if still low risk, but concern for MRSA, add Vancomycin or Linezolid to the first antibiotic choice high risk of mortality (severe illness) or they have recieved iv therapy in past 90 days choose two abx's but avoid two 2 betalactams at once : -zosyn 4.5 g iv q6hr -cefepime 2 g iv q8hr -levofloxacin 750 mg iv q6 hr -imipenem 599 mg iv q6hr -gentamycin -aztreonam ((((+)))vancomycin..........................(2 of above drugs + vanc) generally for 8 days watch procalcitonin level drop, 14 days for MRSA/MSSA remember beta lactams are: Penicillins Cephalosporins Carbapenems Monobactams Beta-lactamase inhibitors Ventilator Associated Pneumonia 3 drug regimen 1. gram positive w/ MRSA activity ex: Vancomycin or Linezolid 2. Beta lactam with GN and antipseudomonal activity ex: zosyn, cefepime, ceftazxidime, imipenem, meropnem, actreonam 3.Non beta lactam with GN antipseudomonal activity ex: levofloxacin, ciprofloxacin, amikcain, gentamicin, tobramycin, polymixin Am i required to calculate Base Deficit? adrenergic receptors alpha 1 - smooth muscle/glands/organs peripheral constriction beta 1 - 1 heart (and kidneys) increase BP, HR, SV both stimulate alpha 2 - presynaptic terminals beta 2 - two lungs bronchodilation (relaxes the smooth muscle/glands/organs) both inhibit Hypotonic- Euvolemic- Hypertonic- Hyponatremia hypotonic (serum osmolality 270) -------- -if clinically wet, patient is retaining free water (CHF/hepatic/renal pt) tx: water restriction, consider diuresis -if clinically dry, pt is losing Na and water -get a urine Na level. if 10 urine Na its likely a GI/diaphoresis problem, if 20 utine Na its a renal cause possibly diuretic overuse. tx: replace Na and treat cause -if patient is euvolemic on exam, consider mild water retention liekly from hypothyroidism and get a TSH level! isotonic (serum osmolality 270-290)------------------ there is an increase in an indisolvable solute such as hyperlipidemia tx: correct hld add statin hypertonic (serum osmolality 290)--------------------- there is an increase in some other solute such as hyperglycemia and kidneys start to dump Na as a solute to dump. tx: treat hyperglycemia **** for an acutely symptomatic patient, correct sodium by 2 meq in the first 2-3 hours the rate of sodium increase should not exceed 6 meq per day in chronic patients and 8 meq per day in acute patients (to AVOID central pontine myelinolysis or osmotic demyelination syndrome) check serum sodium every 2 hours during acute replacement if overcorrection occurs, institute D5W and Desmopressin (DDVAP) best statin drug (HMG-CoA reductase inhibitors) for renally impaired patient atoravastatin or fluvastatin is preferred hint: Rosuvastatin is to be AVOIDED in Renal patients!! no R for renal patients most effective statins? atorvastatin, rosuvastatin, and simvastatin lower LDL the best statin least likely to cause rhabdo because they are not metabolized by P450 pathway? pravastatin, rosuvastatin, fluvastatin always watch out for myalgia s/e complaint! stop the drug reintroduce in a month most common cause of mitral stenosis? rhematic fever when you hear a patient has had an early rheumatic fever event... remember that rheumatic fever (group A streptococcal pharyngitis) can cause mitral stenosis and aortic stenosis shock hemodynamics 1. cardiogenic: 2. obstructive: 3. hypovolemic: 4. distributive: -neurogenic- -anaphylactic- -septic- myocardial infarction technical definition: plaque rupture with thrombosis orthostatic hypotension ... is a part of aging with decreased baroreceptors available to compensate sotalol can treat afib but big side effect is qtc prolongation (which can set you at risk for torsades if it widens even more) pulsus paradoxus drop in blood pressure 10 mmHg with inspiration; can happen when patient has cardiac tamponade or seveere COPD/asthma RV distension pulsus alterans regular rhythm, but force of pulse varies with alternating beats of large and small amplitude; can happen with CHF (ventricular dysfunction/cardiac pathology) CVP waveform - loss of y wave y-descent in a central venous pressure (CVP) waveform can indicate cardiac tamponade. The y-descent is a pressure decrease that occurs when the tricuspid valve opens early in ventricular diastole, before the ECG's P wave. Cardiac tamponade limits ventricular filling, which causes the y-descent to decrease or be lost. CVP waveform - loss of a wave loss of the a wave on a central venous pressure (CVP) tracing can indicate atrial fibrillation (AF) if cardioversion fails (for aflutter) try ibutiliide antiarrythmic echocardiogram screening schedule for valvular disease mild disease - q3-5 years moderate= 1-2 years severe - 6-12 months alpha blocker in aortic stenosis patient... it relaxes smooth muscle, bad idea to slow down/relax the smooth muscle providing preload to the patient because less oompfh to push blood through the stenosis valve (it needs all the pressure behind the blood it can get to overcome the AS). alpha blocker exmaple is prazosin (minpress) in overactive bladder or BPH tx herbedens nodes DIP joint from OA osteophytes ... bouchards nodes are in the proximal PIP joints polymyalgia rheumatica an inflammatory disorder of the muscles and joints characterized by pain and stiffness in the neck, shoulders, upper arms, and hips and thighs pheochromocytoma get the 24hour urine test as best diagnostic test classically palptitaions, diaphoresis, and headaches occur sporadically and without exertion dementia patient sees hallucinations nonpharmacoligc measures first (distract and reassure) , then antipsychotics carcinoid tymor most commonly found in ileum cranial nerves types of diarrhea enterohemmorgagic ecoli -grossly bloody giardia- watery! norovirus - watery shigella - less commonly bloody most common cause of hearing loss cerumen impaction in normal adults but in elederly it is sensorineural hearing loss first line vasopressor after contrast dye reaction epinephrine (& NSS) Lynch syndrome Colorectal cancer Endometrial cancer Ovarian cancer DNA mutation mismatch nucleotide repair Malignant hyperthermia A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. s/s: tx: dantrolene Serotonin Syndrome With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures. -Treatment: cyproheptadine (5-HT2 receptor antagonist). Neuro malignant syndrome s/s: -Stop drug -Be in ICU -Pace-maker -fluid balance -lower fever -Lower BP -Receive anticoagulant